"Procedure"|"Code Type"|"Revenue Code"|"Procedure Description"|"Quantity"|"Payer"|"Plan"|"Inpatient Gross Charges"|"Inpatient Expected Reimbursement"|"Inpatient Max Reimbursement"|"Inpatient Minimal Reimbursement"|"Outpatient Gross Charges"|"Outpatient Expected Reimbursement"|"Outpatient Max Reimbursement"|"Outpatient Minimal Reimbursement"
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.87||||1.87|0.84|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.87||||1.87|0.94|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.87||||1.87|0.75|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.87||||1.87|0.75|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.87||||1.87|0.88|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.87||||1.87|0.77|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.87||||1.87|0.75|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.87||||1.87|0.94|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.87||||1.87|0.84|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.87||||1.87|0.84|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.87||||1.87|0.37|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.87||||1.87|0.26|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.87||||1.87|0|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.87||||1.87|1.29|1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.87||||1.87||1.29|0.26
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.87||||1.87|0|1.29|0.26
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.38||||2.38|1.07|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|0.95|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|0.95|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.12|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|0.98|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|1.07|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|1.07|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.38||||2.38|0.48|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.33|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38|0|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.38||||2.38||1.64|0.33
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38|0|1.64|0.33
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.39||||12.39|5.58|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.39||||12.39|6.2|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.39||||12.39|4.96|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.39||||12.39|4.96|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.39||||12.39|5.82|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.39||||12.39|5.08|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.39||||12.39|4.96|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.39||||12.39|6.2|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.39||||12.39|5.58|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.39||||12.39|5.58|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|12.39||||12.39|2.48|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.39||||12.39|1.73|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.39||||12.39|0|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.39||||12.39|8.55|8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.39||||12.39||8.55|1.73
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.39||||12.39|0|8.55|1.73
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|24.7||||24.7|11.12|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.7||||24.7|12.35|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.7||||24.7|9.88|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.7||||24.7|9.88|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.7||||24.7|11.61|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.7||||24.7|10.13|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|24.7||||24.7|9.88|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.7||||24.7|12.35|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.7||||24.7|11.12|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.7||||24.7|11.12|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|Self-pay|Self-pay|24.7||||24.7|4.94|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.7||||24.7|3.46|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.7||||24.7|0|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|24.7||||24.7|17.04|17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.7||||24.7||17.04|3.46
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|24.7||||24.7|0|17.04|3.46
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|35.57||||35.57|16.01|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|35.57||||35.57|17.79|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.57||||35.57|14.23|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.57||||35.57|14.23|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.57||||35.57|16.72|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|35.57||||35.57|14.58|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|35.57||||35.57|14.23|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|35.57||||35.57|17.79|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.57||||35.57|16.01|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.57||||35.57|16.01|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|Self-pay|Self-pay|35.57||||35.57|7.11|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.57||||35.57|4.98|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.57||||35.57|0|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|35.57||||35.57|24.54|24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.57||||35.57||24.54|4.98
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|35.57||||35.57|0|24.54|4.98
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AARP [1000]|AARP [100000]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AETNA [1015]|AETNA [101529]|2166.63||||2166.63|974.98|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMBETTER [2930]|AMBETTER [293000]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2166.63||||2166.63|1083.32|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2166.63||||2166.63|866.65|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2166.63||||2166.63|866.65|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2166.63||||2166.63|1018.32|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2166.63||||2166.63|888.32|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA [1260]|CIGNA PPO [126025]|2166.63||||2166.63|866.65|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2166.63||||2166.63|1083.32|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2166.63||||2166.63|974.98|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2166.63||||2166.63|974.98|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|Self-pay|Self-pay|2166.63||||2166.63|433.33|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|TML [1980]|TML [198000]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2166.63||||2166.63|303.33|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UNICARE [2040]|UNICARE [204000]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2166.63||||2166.63|0|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WEB TPA [2115]|WEB TPA [211500]|2166.63||||2166.63|1494.97|1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2166.63||||2166.63||1494.97|303.33
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WORKER'S COMP [2125]|TML WC [212537]|2166.63||||2166.63|0|1494.97|303.33
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.15||||11.15|5.02|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.15||||11.15|5.58|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.15||||11.15|4.46|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.15||||11.15|4.46|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.15||||11.15|5.24|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.15||||11.15|4.57|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.15||||11.15|4.46|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.15||||11.15|5.58|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.15||||11.15|5.02|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.15||||11.15|5.02|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|11.15||||11.15|2.23|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.15||||11.15|1.56|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.15||||11.15|0|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.15||||11.15|7.69|7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.15||||11.15||7.69|1.56
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.15||||11.15|0|7.69|1.56
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AARP [1000]|AARP [100000]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|AETNA [101529]|198||||198|89.1|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMBETTER [2930]|AMBETTER [293000]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|99|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|198||||198|79.2|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|198||||198|79.2|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|198||||198|93.06|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|198||||198|81.18|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA [1260]|CIGNA PPO [126025]|198||||198|79.2|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|99|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|89.1|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|89.1|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|Self-pay|Self-pay|198||||198|39.6|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TML [1980]|TML [198000]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|198||||198|27.72|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNICARE [2040]|UNICARE [204000]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198|0|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|198||||198||136.62|27.72
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|TML WC [212537]|198||||198|0|136.62|27.72
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.52|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.15||||1.15|0.58|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.46|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.46|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.54|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.15||||1.15|0.47|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.15||||1.15|0.46|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.15||||1.15|0.58|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.52|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.52|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.15||||1.15|0.23|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.16|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15|0|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.15||||1.15|0.79|0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.16
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.15||||1.15|0|0.79|0.16
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.26||||1.26|0.57|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.26||||1.26|0.63|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.26||||1.26|0.5|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.26||||1.26|0.5|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.26||||1.26|0.59|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.26||||1.26|0.52|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.26||||1.26|0.5|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.26||||1.26|0.63|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.26||||1.26|0.57|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.26||||1.26|0.57|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.26||||1.26|0.25|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.26||||1.26|0.18|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.26||||1.26|0|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.26||||1.26|0.87|0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.26||||1.26||0.87|0.18
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.26||||1.26|0|0.87|0.18
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|20.72||||20.72|9.32|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.72||||20.72|10.36|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.72||||20.72|8.29|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.72||||20.72|8.29|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.72||||20.72|9.74|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.72||||20.72|8.5|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20.72||||20.72|8.29|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.72||||20.72|10.36|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.72||||20.72|9.32|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.72||||20.72|9.32|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|Self-pay|Self-pay|20.72||||20.72|4.14|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.72||||20.72|2.9|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.72||||20.72|0|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20.72||||20.72|14.3|14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.72||||20.72||14.3|2.9
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20.72||||20.72|0|14.3|2.9
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.92||||7.92|3.56|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.92||||7.92|3.96|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.92||||7.92|3.17|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.92||||7.92|3.17|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.92||||7.92|3.72|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.92||||7.92|3.25|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.92||||7.92|3.17|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.92||||7.92|3.96|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.92||||7.92|3.56|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.92||||7.92|3.56|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|7.92||||7.92|1.58|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.92||||7.92|1.11|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.92||||7.92|0|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.92||||7.92|5.46|5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.92||||7.92||5.46|1.11
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.92||||7.92|0|5.46|1.11
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1123.46||||1123.46|561.73|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1123.46||||1123.46|449.38|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1123.46||||1123.46|449.38|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1123.46||||1123.46|528.03|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1123.46||||1123.46|460.62|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1123.46||||1123.46|449.38|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1123.46||||1123.46|561.73|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|1123.46||||1123.46|224.69|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1123.46||||1123.46|157.28|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|1123.46||||1123.46|775.19|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1123.46||||1123.46||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1123.46||||1123.46|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1387.32||||1387.32|693.66|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1387.32||||1387.32|554.93|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1387.32||||1387.32|554.93|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1387.32||||1387.32|652.04|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1387.32||||1387.32|568.8|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1387.32||||1387.32|554.93|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1387.32||||1387.32|693.66|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|1387.32||||1387.32|277.46|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1387.32||||1387.32|194.22|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1387.32||||1387.32|957.25|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1387.32||||1387.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1387.32||||1387.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|391.32||||391.32|195.66|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|391.32||||391.32|156.53|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|391.32||||391.32|156.53|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|391.32||||391.32|183.92|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|391.32||||391.32|160.44|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|391.32||||391.32|156.53|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|391.32||||391.32|195.66|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|391.32||||391.32|78.26|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|391.32||||391.32|54.78|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|391.32||||391.32|0|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|391.32||||391.32|270.01|957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|391.32||||391.32||957.25|54.78
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|391.32||||391.32|0|957.25|54.78
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|48.84||||48.84|21.98|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48.84||||48.84|24.42|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.84||||48.84|19.54|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.84||||48.84|19.54|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.84||||48.84|22.95|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48.84||||48.84|20.02|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|48.84||||48.84|19.54|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48.84||||48.84|24.42|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.84||||48.84|21.98|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.84||||48.84|21.98|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|48.84||||48.84|9.77|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.84||||48.84|6.84|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.84||||48.84|0|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|48.84||||48.84|33.7|33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.84||||48.84||33.7|6.84
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|48.84||||48.84|0|33.7|6.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|1.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.18||||4.18|1.67|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|1.67|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.18||||4.18|1.96|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|1.71|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|1.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|1.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.18||||4.18|0.59|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18|0|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.18||||4.18||2.88|0.59
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18|0|2.88|0.59
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.73||||5.73|2.58|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.73||||5.73|2.87|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.73||||5.73|2.29|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.73||||5.73|2.29|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.73||||5.73|2.69|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.73||||5.73|2.35|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.73||||5.73|2.29|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.73||||5.73|2.87|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.73||||5.73|2.58|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.73||||5.73|2.58|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|Self-pay|Self-pay|5.73||||5.73|1.15|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.73||||5.73|0.8|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.73||||5.73|0|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.73||||5.73|3.95|3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.73||||5.73||3.95|0.8
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.73||||5.73|0|3.95|0.8
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.7||||2.7|1.22|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.7||||2.7|1.35|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.7||||2.7|1.08|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.7||||2.7|1.08|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.7||||2.7|1.27|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.7||||2.7|1.11|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.7||||2.7|1.08|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.7||||2.7|1.35|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.7||||2.7|1.22|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.7||||2.7|1.22|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.7||||2.7|0.54|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.7||||2.7|0.38|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.7||||2.7|0|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.7||||2.7|1.86|1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.7||||2.7||1.86|0.38
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.7||||2.7|0|1.86|0.38
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|52.28||||52.28|23.53|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.28||||52.28|26.14|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.28||||52.28|20.91|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.28||||52.28|20.91|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.28||||52.28|24.57|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.28||||52.28|21.43|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|52.28||||52.28|20.91|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.28||||52.28|26.14|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.28||||52.28|23.53|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.28||||52.28|23.53|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|52.28||||52.28|10.46|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.28||||52.28|7.32|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.28||||52.28|0|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|52.28||||52.28|36.07|36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.28||||52.28||36.07|7.32
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|52.28||||52.28|0|36.07|7.32
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|43.04||||43.04|19.37|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|43.04||||43.04|21.52|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.04||||43.04|17.22|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.04||||43.04|17.22|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.04||||43.04|20.23|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|43.04||||43.04|17.65|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|43.04||||43.04|17.22|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|43.04||||43.04|21.52|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.04||||43.04|19.37|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.04||||43.04|19.37|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|43.04||||43.04|8.61|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.04||||43.04|6.03|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.04||||43.04|0|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|43.04||||43.04|29.7|29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.04||||43.04||29.7|6.03
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|43.04||||43.04|0|29.7|6.03
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|34.32||||34.32|15.44|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34.32||||34.32|17.16|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.32||||34.32|13.73|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.32||||34.32|13.73|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.32||||34.32|16.13|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34.32||||34.32|14.07|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|34.32||||34.32|13.73|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34.32||||34.32|17.16|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.32||||34.32|15.44|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.32||||34.32|15.44|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|34.32||||34.32|6.86|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.32||||34.32|4.8|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.32||||34.32|0|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|34.32||||34.32|23.68|23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.32||||34.32||23.68|4.8
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|34.32||||34.32|0|23.68|4.8
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.49||||0.49|0.22|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.49||||0.49|0.25|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.49||||0.49|0.2|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.49||||0.49|0.2|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.49||||0.49|0.23|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.49||||0.49|0.2|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.49||||0.49|0.2|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.49||||0.49|0.25|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.49||||0.49|0.22|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.49||||0.49|0.22|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.49||||0.49|0.1|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.49||||0.49|0.07|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.49||||0.49|0|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.49||||0.49|0.34|0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.49||||0.49||0.34|0.07
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.49||||0.49|0|0.34|0.07
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|25.74||||25.74|11.58|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.74||||25.74|12.87|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.74||||25.74|10.3|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.74||||25.74|10.3|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.74||||25.74|12.1|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.74||||25.74|10.55|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|25.74||||25.74|10.3|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.74||||25.74|12.87|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.74||||25.74|11.58|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.74||||25.74|11.58|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|25.74||||25.74|5.15|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.74||||25.74|3.6|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.74||||25.74|0|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|25.74||||25.74|17.76|17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.74||||25.74||17.76|3.6
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|25.74||||25.74|0|17.76|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|12.15||||12.15|5.47|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.15||||12.15|6.08|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.15||||12.15|4.86|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.15||||12.15|4.86|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.15||||12.15|5.71|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.15||||12.15|4.98|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.15||||12.15|4.86|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.15||||12.15|6.08|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.15||||12.15|5.47|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.15||||12.15|5.47|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|12.15||||12.15|2.43|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.15||||12.15|1.7|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.15||||12.15|0|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.15||||12.15|8.38|8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.15||||12.15||8.38|1.7
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.15||||12.15|0|8.38|1.7
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AARP [1000]|AARP [100000]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|15.98||||15.98|7.19|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AMBETTER [2930]|AMBETTER [293000]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.98||||15.98|7.99|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.98||||15.98|6.39|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.98||||15.98|6.39|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.98||||15.98|7.51|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.98||||15.98|6.55|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|15.98||||15.98|6.39|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.98||||15.98|7.99|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.98||||15.98|7.19|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.98||||15.98|7.19|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|Self-pay|Self-pay|15.98||||15.98|3.2|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|TML [1980]|TML [198000]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.98||||15.98|2.24|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|UNICARE [2040]|UNICARE [204000]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|WEB TPA [2115]|WEB TPA [211500]|15.98||||15.98|11.03|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.98||||15.98||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|15.98||||15.98|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|9.64||||9.64|4.34|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.64||||9.64|4.82|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.64||||9.64|3.86|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.64||||9.64|3.86|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.64||||9.64|4.53|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.64||||9.64|3.95|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|9.64||||9.64|3.86|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.64||||9.64|4.82|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.64||||9.64|4.34|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.64||||9.64|4.34|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|9.64||||9.64|1.93|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.64||||9.64|1.35|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.64||||9.64|0|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|9.64||||9.64|6.65|11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.64||||9.64||11.03|1.35
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|9.64||||9.64|0|11.03|1.35
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AARP [1000]|AARP [100000]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA [1015]|AETNA [101529]|588.86||||588.86|264.99|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|588.86||||588.86|235.54|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|588.86||||588.86|235.54|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|588.86||||588.86|276.76|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|588.86||||588.86|241.43|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|588.86||||588.86|235.54|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|588.86||||588.86|264.99|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|588.86||||588.86|264.99|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|Self-pay|Self-pay|588.86||||588.86|117.77|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TML [1980]|TML [198000]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|588.86||||588.86|82.44|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|588.86||||588.86|0|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|588.86||||588.86||406.31|82.44
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AARP [1000]|AARP [100000]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA [1015]|AETNA [101529]|588.86||||588.86|264.99|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|588.86||||588.86|235.54|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|588.86||||588.86|235.54|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|588.86||||588.86|276.76|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|588.86||||588.86|241.43|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA [1260]|CIGNA PPO [126025]|588.86||||588.86|235.54|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|588.86||||588.86|264.99|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|588.86||||588.86|264.99|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|Self-pay|Self-pay|588.86||||588.86|117.77|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TML [1980]|TML [198000]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|588.86||||588.86|82.44|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|588.86||||588.86|0|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|588.86||||588.86||406.31|82.44
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WORKER'S COMP [2125]|TML WC [212537]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AARP [1000]|AARP [100000]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|588.86||||588.86|264.99|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|588.86||||588.86|235.54|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|588.86||||588.86|235.54|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|588.86||||588.86|276.76|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|588.86||||588.86|241.43|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|588.86||||588.86|235.54|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|588.86||||588.86|264.99|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|588.86||||588.86|264.99|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|Self-pay|Self-pay|588.86||||588.86|117.77|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TML [1980]|TML [198000]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|588.86||||588.86|82.44|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|588.86||||588.86|0|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|588.86||||588.86||406.31|82.44
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|588.86||||588.86|0|406.31|82.44
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|295.42||||295.42|132.94|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|295.42||||295.42|147.71|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|295.42||||295.42|118.17|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|295.42||||295.42|118.17|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|295.42||||295.42|138.85|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|295.42||||295.42|121.12|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|295.42||||295.42|118.17|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|295.42||||295.42|147.71|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|295.42||||295.42|132.94|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|295.42||||295.42|132.94|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|295.42||||295.42|59.08|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|295.42||||295.42|41.36|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|295.42||||295.42|0|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|295.42||||295.42|203.84|203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|295.42||||295.42||203.84|41.36
1031|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|295.42||||295.42|0|203.84|41.36
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AARP [1000]|AARP [100000]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1168.73||||1168.73|584.37|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1168.73||||1168.73|467.49|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1168.73||||1168.73|467.49|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1168.73||||1168.73|549.3|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1168.73||||1168.73|479.18|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1168.73||||1168.73|467.49|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1168.73||||1168.73|584.37|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|Self-pay|Self-pay|1168.73||||1168.73|233.75|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|TML [1980]|TML [198000]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1168.73||||1168.73|163.62|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1168.73||||1168.73|0|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1168.73||||1168.73|806.42|806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1168.73||||1168.73||806.42|163.62
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1168.73||||1168.73|0|806.42|163.62
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1133.55||||1133.55|566.78|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1133.55||||1133.55|453.42|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1133.55||||1133.55|453.42|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1133.55||||1133.55|532.77|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1133.55||||1133.55|464.76|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1133.55||||1133.55|453.42|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1133.55||||1133.55|566.78|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|Self-pay|Self-pay|1133.55||||1133.55|226.71|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|TML [1980]|TML [198000]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1133.55||||1133.55|158.7|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1133.55||||1133.55|0|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|1133.55||||1133.55|782.15|782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1133.55||||1133.55||782.15|158.7
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1133.55||||1133.55|0|782.15|158.7
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1290.96||||1290.96|645.48|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1290.96||||1290.96|516.38|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1290.96||||1290.96|516.38|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1290.96||||1290.96|606.75|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1290.96||||1290.96|529.29|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1290.96||||1290.96|516.38|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1290.96||||1290.96|645.48|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1290.96||||1290.96|258.19|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1290.96||||1290.96|180.73|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1290.96||||1290.96|890.76|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1290.96||||1290.96||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1290.96||||1290.96|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.6||||336.6|168.3|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.6||||336.6|168.3|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.6||||336.6|158.2|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.6||||336.6|158.2|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.6||||336.6|138.01|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.6||||336.6|138.01|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|336.6||||336.6|134.64|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.6||||336.6|168.3|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.6||||336.6|168.3|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|336.6||||336.6|67.32|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|336.6||||336.6|67.32|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.6||||336.6|47.12|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.6||||336.6|47.12|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|336.6||||336.6|232.25|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336.6||||336.6||890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|336.6||||336.6|0|890.76|47.12
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|336.6||||336.6|0|890.76|47.12
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.71||||6.71|3.02|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.71||||6.71|3.36|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.71||||6.71|2.68|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.71||||6.71|2.68|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.71||||6.71|3.15|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.71||||6.71|2.75|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.71||||6.71|2.68|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.71||||6.71|3.36|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.71||||6.71|3.02|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.71||||6.71|3.02|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|6.71||||6.71|1.34|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.71||||6.71|0.94|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.71||||6.71|0|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.71||||6.71|4.63|4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.71||||6.71||4.63|0.94
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.71||||6.71|0|4.63|0.94
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|44||||44|19.8|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44||||44|22|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44||||44|17.6|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44||||44|17.6|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44||||44|20.68|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44||||44|18.04|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|44||||44|17.6|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44||||44|22|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44||||44|19.8|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44||||44|19.8|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|44||||44|8.8|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44||||44|6.16|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44||||44|0|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|44||||44|30.36|30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44||||44||30.36|6.16
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|44||||44|0|30.36|6.16
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14.23||||14.23|6.4|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.23||||14.23|7.12|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.23||||14.23|5.69|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.23||||14.23|5.69|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.23||||14.23|6.69|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.23||||14.23|5.83|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.23||||14.23|5.69|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.23||||14.23|7.12|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.23||||14.23|6.4|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.23||||14.23|6.4|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|Self-pay|Self-pay|14.23||||14.23|2.85|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.23||||14.23|1.99|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.23||||14.23|0|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.23||||14.23|9.82|9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.23||||14.23||9.82|1.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.23||||14.23|0|9.82|1.99
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AARP [1000]|AARP [100000]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|AETNA [101529]|21.45||||21.45|9.65|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.45||||21.45|10.73|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.45||||21.45|8.58|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.45||||21.45|8.58|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.45||||21.45|10.08|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.45||||21.45|8.79|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|21.45||||21.45|8.58|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.45||||21.45|10.73|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.45||||21.45|9.65|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.45||||21.45|9.65|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|Self-pay|Self-pay|21.45||||21.45|4.29|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TML [1980]|TML [198000]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.45||||21.45|3|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.45||||21.45|0|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|21.45||||21.45|14.8|14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.45||||21.45||14.8|3
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|21.45||||21.45|0|14.8|3
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AARP [1000]|AARP [100000]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AETNA [1015]|AETNA [101529]|52.67||||52.67|23.7|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMBETTER [2930]|AMBETTER [293000]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.67||||52.67|26.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.67||||52.67|21.07|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.67||||52.67|21.07|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.67||||52.67|24.75|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.67||||52.67|21.59|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA [1260]|CIGNA PPO [126025]|52.67||||52.67|21.07|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.67||||52.67|26.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.67||||52.67|23.7|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.67||||52.67|23.7|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|Self-pay|Self-pay|52.67||||52.67|10.53|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|TML [1980]|TML [198000]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.67||||52.67|7.37|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UNICARE [2040]|UNICARE [204000]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.67||||52.67|0|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WEB TPA [2115]|WEB TPA [211500]|52.67||||52.67|36.34|36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.67||||52.67||36.34|7.37
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WORKER'S COMP [2125]|TML WC [212537]|52.67||||52.67|0|36.34|7.37
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.81||||7.81|3.51|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.81||||7.81|3.91|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.81||||7.81|3.12|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.81||||7.81|3.12|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.81||||7.81|3.67|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.81||||7.81|3.2|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.81||||7.81|3.12|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.81||||7.81|3.91|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.81||||7.81|3.51|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.81||||7.81|3.51|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.81||||7.81|1.56|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.81||||7.81|1.09|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.81||||7.81|0|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.81||||7.81|5.39|5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.81||||7.81||5.39|1.09
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.81||||7.81|0|5.39|1.09
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.68||||6.68|3.01|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.68||||6.68|3.34|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.68||||6.68|2.67|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.68||||6.68|2.67|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.68||||6.68|3.14|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.68||||6.68|2.74|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.68||||6.68|2.67|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.68||||6.68|3.34|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.68||||6.68|3.01|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.68||||6.68|3.01|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|Self-pay|Self-pay|6.68||||6.68|1.34|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TML [1980]|TML [198000]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.68||||6.68|0.94|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.68||||6.68|0|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.68||||6.68|4.61|4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.68||||6.68||4.61|0.94
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.68||||6.68|0|4.61|0.94
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.78||||7.78|3.5|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.78||||7.78|3.89|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.78||||7.78|3.11|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.78||||7.78|3.11|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.78||||7.78|3.66|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.78||||7.78|3.19|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.78||||7.78|3.11|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.78||||7.78|3.89|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.78||||7.78|3.5|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.78||||7.78|3.5|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|Self-pay|Self-pay|7.78||||7.78|1.56|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TML [1980]|TML [198000]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.78||||7.78|1.09|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.78||||7.78|0|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.78||||7.78|5.37|5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.78||||7.78||5.37|1.09
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.78||||7.78|0|5.37|1.09
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|39.47||||39.47|17.76|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.47||||39.47|19.74|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.47||||39.47|15.79|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.47||||39.47|15.79|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.47||||39.47|18.55|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.47||||39.47|16.18|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|39.47||||39.47|15.79|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.47||||39.47|19.74|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.47||||39.47|17.76|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.47||||39.47|17.76|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|Self-pay|Self-pay|39.47||||39.47|7.89|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.47||||39.47|5.53|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.47||||39.47|0|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|39.47||||39.47|27.23|27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.47||||39.47||27.23|5.53
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|39.47||||39.47|0|27.23|5.53
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.01||||9.01|4.05|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.01||||9.01|4.51|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.01||||9.01|3.6|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.01||||9.01|3.6|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.01||||9.01|4.23|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.01||||9.01|3.69|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.01||||9.01|3.6|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.01||||9.01|4.51|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.01||||9.01|4.05|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.01||||9.01|4.05|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|Self-pay|Self-pay|9.01||||9.01|1.8|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.01||||9.01|1.26|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.01||||9.01|0|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.01||||9.01|6.22|6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.01||||9.01||6.22|1.26
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.01||||9.01|0|6.22|1.26
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.04||||6.04|2.72|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.04||||6.04|3.02|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.04||||6.04|2.42|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.04||||6.04|2.42|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.04||||6.04|2.84|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.04||||6.04|2.48|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.04||||6.04|2.42|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.04||||6.04|3.02|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.04||||6.04|2.72|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.04||||6.04|2.72|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|6.04||||6.04|1.21|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.04||||6.04|0.85|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.04||||6.04|0|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.04||||6.04|4.17|4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.04||||6.04||4.17|0.85
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.04||||6.04|0|4.17|0.85
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.98||||8.98|4.04|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.98||||8.98|4.49|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.98||||8.98|3.59|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.98||||8.98|3.59|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.98||||8.98|4.22|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.98||||8.98|3.68|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.98||||8.98|3.59|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.98||||8.98|4.49|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.98||||8.98|4.04|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.98||||8.98|4.04|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|Self-pay|Self-pay|8.98||||8.98|1.8|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|TML [1980]|TML [198000]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.98||||8.98|1.26|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.98||||8.98|0|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.98||||8.98|6.2|6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.98||||8.98||6.2|1.26
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.98||||8.98|0|6.2|1.26
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.74|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.65||||1.65|0.83|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.66|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.66|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|0.78|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.65||||1.65|0.68|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.65||||1.65|0.66|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.65||||1.65|0.83|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.74|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.74|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.33|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.23|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65|0|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.65||||1.65|1.14|1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.23
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.65||||1.65|0|1.14|0.23
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.26||||2.26|1.02|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.26||||2.26|1.13|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.26||||2.26|0.9|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.26||||2.26|0.9|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.26||||2.26|1.06|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.26||||2.26|0.93|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.26||||2.26|0.9|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.26||||2.26|1.13|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.26||||2.26|1.02|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.26||||2.26|1.02|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.26||||2.26|0.45|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.26||||2.26|0.32|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.26||||2.26|0|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.26||||2.26|1.56|1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.26||||2.26||1.56|0.32
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.26||||2.26|0|1.56|0.32
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|4.82||||4.82|2.17|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.82||||4.82|2.41|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.82||||4.82|1.93|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.82||||4.82|1.93|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.82||||4.82|2.27|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.82||||4.82|1.98|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.82||||4.82|1.93|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.82||||4.82|2.41|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.82||||4.82|2.17|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.82||||4.82|2.17|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|4.82||||4.82|0.96|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.82||||4.82|0.67|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.82||||4.82|0|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.82||||4.82|3.33|3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.82||||4.82||3.33|0.67
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.82||||4.82|0|3.33|0.67
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|7.4||||7.4|3.33|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.4||||7.4|3.7|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.4||||7.4|2.96|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.4||||7.4|2.96|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.4||||7.4|3.48|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.4||||7.4|3.03|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.4||||7.4|2.96|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.4||||7.4|3.7|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.4||||7.4|3.33|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.4||||7.4|3.33|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|7.4||||7.4|1.48|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.4||||7.4|1.04|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.4||||7.4|0|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.4||||7.4|5.11|5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.4||||7.4||5.11|1.04
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.4||||7.4|0|5.11|1.04
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AARP [1000]|AARP [100000]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|AETNA [101529]|303.33||||303.33|136.5|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMBETTER [2930]|AMBETTER [293000]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.33||||303.33|151.67|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.33||||303.33|121.33|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.33||||303.33|121.33|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.33||||303.33|142.57|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.33||||303.33|124.37|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA PPO [126025]|303.33||||303.33|121.33|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.33||||303.33|151.67|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.33||||303.33|136.5|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.33||||303.33|136.5|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|Self-pay|Self-pay|303.33||||303.33|60.67|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TML [1980]|TML [198000]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.33||||303.33|42.47|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNICARE [2040]|UNICARE [204000]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.33||||303.33|0|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WEB TPA [2115]|WEB TPA [211500]|303.33||||303.33|209.3|209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.33||||303.33||209.3|42.47
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TML WC [212537]|303.33||||303.33|0|209.3|42.47
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|15.55||||15.55|7|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.55||||15.55|7.78|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.55||||15.55|6.22|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.55||||15.55|6.22|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.55||||15.55|7.31|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.55||||15.55|6.38|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|15.55||||15.55|6.22|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.55||||15.55|7.78|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.55||||15.55|7|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.55||||15.55|7|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|15.55||||15.55|3.11|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.55||||15.55|2.18|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.55||||15.55|0|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|15.55||||15.55|10.73|10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.55||||15.55||10.73|2.18
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|15.55||||15.55|0|10.73|2.18
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.35||||0.35|0.16|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.35||||0.35|0.18|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.35||||0.35|0.14|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.35||||0.35|0.14|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.35||||0.35|0.16|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.35||||0.35|0.14|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.35||||0.35|0.14|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.35||||0.35|0.18|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.35||||0.35|0.16|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.35||||0.35|0.16|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|Self-pay|Self-pay|0.35||||0.35|0.07|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|TML [1980]|TML [198000]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.35||||0.35|0.05|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.35||||0.35|0|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.35||||0.35|0.24|0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.35||||0.35||0.24|0.05
10491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.35||||0.35|0|0.24|0.05
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|3.69||||3.69|1.66|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.69||||3.69|1.85|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.69||||3.69|1.48|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.69||||3.69|1.48|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.69||||3.69|1.73|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.69||||3.69|1.51|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|3.69||||3.69|1.48|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.69||||3.69|1.85|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.69||||3.69|1.66|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.69||||3.69|1.66|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|3.69||||3.69|0.74|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.69||||3.69|0.52|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.69||||3.69|0|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|3.69||||3.69|2.55|2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.69||||3.69||2.55|0.52
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|3.69||||3.69|0|2.55|0.52
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AARP [1000]|AARP [100000]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AETNA [1015]|AETNA [101529]|80.16||||80.16|36.07|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMBETTER [2930]|AMBETTER [293000]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80.16||||80.16|40.08|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80.16||||80.16|32.06|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80.16||||80.16|32.06|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80.16||||80.16|37.68|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80.16||||80.16|32.87|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA [1260]|CIGNA PPO [126025]|80.16||||80.16|32.06|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80.16||||80.16|40.08|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.16||||80.16|36.07|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80.16||||80.16|36.07|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|Self-pay|Self-pay|80.16||||80.16|16.03|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|TML [1980]|TML [198000]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80.16||||80.16|11.22|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UNICARE [2040]|UNICARE [204000]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80.16||||80.16|0|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WEB TPA [2115]|WEB TPA [211500]|80.16||||80.16|55.31|55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80.16||||80.16||55.31|11.22
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WORKER'S COMP [2125]|TML WC [212537]|80.16||||80.16|0|55.31|11.22
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.72||||1.72|0.77|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.72||||1.72|0.86|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.72||||1.72|0.69|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.72||||1.72|0.69|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.72||||1.72|0.81|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.72||||1.72|0.71|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.72||||1.72|0.69|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.72||||1.72|0.86|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.72||||1.72|0.77|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.72||||1.72|0.77|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|1.72||||1.72|0.34|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.72||||1.72|0.24|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.72||||1.72|0|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.72||||1.72|1.19|1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.72||||1.72||1.19|0.24
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.72||||1.72|0|1.19|0.24
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.6||||6.6|2.97|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.6||||6.6|3.3|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.6||||6.6|2.64|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.6||||6.6|2.64|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.6||||6.6|3.1|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.6||||6.6|2.71|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.6||||6.6|2.64|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.6||||6.6|3.3|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.6||||6.6|2.97|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.6||||6.6|2.97|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.6||||6.6|1.32|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.6||||6.6|0.92|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.6||||6.6|0|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.6||||6.6|4.55|4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.6||||6.6||4.55|0.92
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.6||||6.6|0|4.55|0.92
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|24.95||||24.95|11.23|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.95||||24.95|12.48|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.95||||24.95|9.98|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.95||||24.95|9.98|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.95||||24.95|11.73|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.95||||24.95|10.23|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|24.95||||24.95|9.98|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.95||||24.95|12.48|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.95||||24.95|11.23|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.95||||24.95|11.23|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|24.95||||24.95|4.99|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.95||||24.95|3.49|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.95||||24.95|0|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|24.95||||24.95|17.22|17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.95||||24.95||17.22|3.49
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|24.95||||24.95|0|17.22|3.49
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.1||||1.1|0.5|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.1||||1.1|0.55|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.1||||1.1|0.44|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.1||||1.1|0.44|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.1||||1.1|0.52|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.1||||1.1|0.45|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.1||||1.1|0.44|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.1||||1.1|0.55|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.1||||1.1|0.5|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.1||||1.1|0.5|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|1.1||||1.1|0.22|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.1||||1.1|0.15|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.1||||1.1|0|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.1||||1.1|0.76|0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.1||||1.1||0.76|0.15
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.1||||1.1|0|0.76|0.15
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|153.78||||153.78|69.2|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|153.78||||153.78|76.89|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|153.78||||153.78|61.51|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|153.78||||153.78|61.51|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|153.78||||153.78|72.28|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|153.78||||153.78|63.05|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|153.78||||153.78|61.51|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|153.78||||153.78|76.89|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|153.78||||153.78|69.2|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|153.78||||153.78|69.2|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|153.78||||153.78|30.76|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TML [1980]|TML [198000]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|153.78||||153.78|21.53|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNICARE [2040]|UNICARE [204000]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|153.78||||153.78|0|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|153.78||||153.78|106.11|106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|153.78||||153.78||106.11|21.53
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|153.78||||153.78|0|106.11|21.53
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|80.26||||80.26|36.12|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80.26||||80.26|40.13|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80.26||||80.26|32.1|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80.26||||80.26|32.1|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80.26||||80.26|37.72|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80.26||||80.26|32.91|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|80.26||||80.26|32.1|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80.26||||80.26|40.13|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.26||||80.26|36.12|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80.26||||80.26|36.12|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|Self-pay|Self-pay|80.26||||80.26|16.05|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|TML [1980]|TML [198000]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80.26||||80.26|11.24|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80.26||||80.26|0|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|80.26||||80.26|55.38|55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80.26||||80.26||55.38|11.24
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|80.26||||80.26|0|55.38|11.24
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.9||||21.9|9.86|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.9||||21.9|10.95|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.9||||21.9|8.76|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.9||||21.9|8.76|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.9||||21.9|10.29|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.9||||21.9|8.98|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.9||||21.9|8.76|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.9||||21.9|10.95|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.9||||21.9|9.86|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.9||||21.9|9.86|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|21.9||||21.9|4.38|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.9||||21.9|3.07|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.9||||21.9|0|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.9||||21.9|15.11|15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.9||||21.9||15.11|3.07
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.9||||21.9|0|15.11|3.07
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AARP [1000]|AARP [100000]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA [1015]|AETNA [101529]|59.4||||59.4|26.73|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.4||||59.4|23.76|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.4||||59.4|23.76|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.4||||59.4|27.92|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|24.35|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|26.73|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|26.73|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|Self-pay|Self-pay|59.4||||59.4|11.88|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|TML [1980]|TML [198000]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.4||||59.4|8.32|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNICARE [2040]|UNICARE [204000]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4|0|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.4||||59.4||40.99|8.32
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4|0|40.99|8.32
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|118.8||||118.8|53.46|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.8||||118.8|59.4|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.8||||118.8|47.52|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.8||||118.8|47.52|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.8||||118.8|55.84|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.8||||118.8|48.71|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|118.8||||118.8|47.52|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.8||||118.8|59.4|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.8||||118.8|53.46|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.8||||118.8|53.46|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|Self-pay|Self-pay|118.8||||118.8|23.76|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TML [1980]|TML [198000]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.8||||118.8|16.63|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNICARE [2040]|UNICARE [204000]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.8||||118.8|0|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|118.8||||118.8|81.97|81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.8||||118.8||81.97|16.63
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|118.8||||118.8|0|81.97|16.63
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|71.28|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|63.36|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|63.36|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|74.45|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|64.94|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|71.28|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|71.28|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|158.4||||158.4|31.68|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|22.18|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|0|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4||109.3|22.18
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|0|109.3|22.18
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|237.6||||237.6|106.92|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.6||||237.6|118.8|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.6||||237.6|95.04|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.6||||237.6|95.04|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.6||||237.6|111.67|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.6||||237.6|97.42|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|237.6||||237.6|95.04|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.6||||237.6|118.8|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.6||||237.6|106.92|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.6||||237.6|106.92|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|237.6||||237.6|47.52|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.6||||237.6|33.26|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.6||||237.6|0|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|237.6||||237.6|163.94|163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237.6||||237.6||163.94|33.26
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|237.6||||237.6|0|163.94|33.26
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.05||||15.05|6.77|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.05||||15.05|7.53|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.05||||15.05|6.02|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.05||||15.05|6.02|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.05||||15.05|7.07|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.05||||15.05|6.17|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.05||||15.05|6.02|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.05||||15.05|7.53|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.05||||15.05|6.77|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.05||||15.05|6.77|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|15.05||||15.05|3.01|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.05||||15.05|2.11|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.05||||15.05|0|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.05||||15.05|10.38|10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.05||||15.05||10.38|2.11
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.05||||15.05|0|10.38|2.11
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AARP [1000]|AARP [100000]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|363.59||||363.59|163.62|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMBETTER [2930]|AMBETTER [293000]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|363.59||||363.59|181.8|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363.59||||363.59|145.44|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363.59||||363.59|145.44|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363.59||||363.59|170.89|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|363.59||||363.59|149.07|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA PPO [126025]|363.59||||363.59|145.44|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|363.59||||363.59|181.8|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363.59||||363.59|163.62|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363.59||||363.59|163.62|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|Self-pay|Self-pay|363.59||||363.59|72.72|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TML [1980]|TML [198000]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363.59||||363.59|50.9|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNICARE [2040]|UNICARE [204000]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363.59||||363.59|0|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WEB TPA [2115]|WEB TPA [211500]|363.59||||363.59|250.88|250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363.59||||363.59||250.88|50.9
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TML WC [212537]|363.59||||363.59|0|250.88|50.9
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AARP [1000]|AARP [100000]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA [1015]|AETNA [101529]|6.82||||6.82|3.07|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMBETTER [2930]|AMBETTER [293000]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.82||||6.82|3.41|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.82||||6.82|2.73|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.82||||6.82|2.73|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.82||||6.82|3.21|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.82||||6.82|2.8|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.82||||6.82|2.73|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.82||||6.82|3.41|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.82||||6.82|3.07|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.82||||6.82|3.07|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|Self-pay|Self-pay|6.82||||6.82|1.36|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TML [1980]|TML [198000]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.82||||6.82|0.95|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNICARE [2040]|UNICARE [204000]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.82||||6.82|0|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WEB TPA [2115]|WEB TPA [211500]|6.82||||6.82|4.71|4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.82||||6.82||4.71|0.95
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.82||||6.82|0|4.71|0.95
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AARP [1000]|AARP [100000]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA [1015]|AETNA [101529]|6.08||||6.08|2.74|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMBETTER [2930]|AMBETTER [293000]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.08||||6.08|3.04|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.08||||6.08|2.43|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.08||||6.08|2.43|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.08||||6.08|2.86|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.08||||6.08|2.49|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA [1260]|CIGNA PPO [126025]|6.08||||6.08|2.43|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.08||||6.08|3.04|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.08||||6.08|2.74|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.08||||6.08|2.74|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|Self-pay|Self-pay|6.08||||6.08|1.22|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TML [1980]|TML [198000]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.08||||6.08|0.85|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNICARE [2040]|UNICARE [204000]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.08||||6.08|0|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WEB TPA [2115]|WEB TPA [211500]|6.08||||6.08|4.2|4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.08||||6.08||4.2|0.85
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WORKER'S COMP [2125]|TML WC [212537]|6.08||||6.08|0|4.2|0.85
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AARP [1000]|AARP [100000]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AARP [1000]|AARP [100000]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA [1015]|AETNA [101529]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA [1015]|AETNA [101529]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.78||||15.78|7.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.78||||15.78|7.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.78||||15.78|7.42|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.78||||15.78|7.42|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.78||||15.78|6.47|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.78||||15.78|6.47|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|15.78||||15.78|6.31|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.78||||15.78|7.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.78||||15.78|7.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.78||||15.78|7.1|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|Self-pay|Self-pay|15.78||||15.78|3.16|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|Self-pay|Self-pay|15.78||||15.78|3.16|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|TML [1980]|TML [198000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|TML [1980]|TML [198000]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.78||||15.78|2.21|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.78||||15.78|2.21|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNICARE [2040]|UNICARE [204000]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNICARE [2040]|UNICARE [204000]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|15.78||||15.78|10.89|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.78||||15.78||10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|15.78||||15.78|0|10.89|2.21
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|15.78||||15.78|0|10.89|2.21
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|104.93||||104.93|47.22|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104.93||||104.93|52.47|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104.93||||104.93|41.97|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104.93||||104.93|41.97|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104.93||||104.93|49.32|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104.93||||104.93|43.02|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|104.93||||104.93|41.97|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104.93||||104.93|52.47|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104.93||||104.93|47.22|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104.93||||104.93|47.22|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|104.93||||104.93|20.99|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104.93||||104.93|14.69|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104.93||||104.93|0|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|104.93||||104.93|72.4|72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104.93||||104.93||72.4|14.69
106490|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|104.93||||104.93|0|72.4|14.69
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AARP [1000]|AARP [100000]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|AETNA [101529]|118.78||||118.78|53.45|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMBETTER [2930]|AMBETTER [293000]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.78||||118.78|59.39|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.78||||118.78|47.51|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.78||||118.78|47.51|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.78||||118.78|55.83|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.78||||118.78|48.7|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA [1260]|CIGNA PPO [126025]|118.78||||118.78|47.51|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GROUP PENSION ADMIN [1450]|GPA [145000]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.78||||118.78|59.39|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.78||||118.78|53.45|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.78||||118.78|53.45|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PHCS [1780]|PHCS MULTIPLAN [178000]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|Self-pay|Self-pay|118.78||||118.78|23.76|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TML [1980]|TML [198000]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.78||||118.78|16.63|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNICARE [2040]|UNICARE [204000]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.78||||118.78|0|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WEB TPA [2115]|WEB TPA [211500]|118.78||||118.78|81.96|81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.78||||118.78||81.96|16.63
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|TML WC [212537]|118.78||||118.78|0|81.96|16.63
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AARP [1000]|AARP [100000]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.67|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.38|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.38|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|2.79|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|2.44|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.67|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.67|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|Self-pay|Self-pay|5.94||||5.94|1.19|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|0.83|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNICARE [2040]|UNICARE [204000]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94|0|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|0.83
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94|0|4.1|0.83
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|5.28||||5.28|2.38|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.28||||5.28|2.11|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.28||||5.28|2.11|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.28||||5.28|2.48|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|2.16|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|2.38|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.28||||5.28|2.38|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|5.28||||5.28|1.06|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.28||||5.28|0.74|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.28||||5.28|0|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.28||||5.28||3.64|0.74
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28|0|3.64|0.74
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|38.83||||38.83|17.47|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.83||||38.83|19.42|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.83||||38.83|15.53|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.83||||38.83|15.53|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.83||||38.83|18.25|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.83||||38.83|15.92|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|38.83||||38.83|15.53|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.83||||38.83|19.42|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.83||||38.83|17.47|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.83||||38.83|17.47|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|38.83||||38.83|7.77|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.83||||38.83|5.44|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.83||||38.83|0|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|38.83||||38.83|26.79|26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.83||||38.83||26.79|5.44
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|38.83||||38.83|0|26.79|5.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AARP [1000]|AARP [100000]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA [1015]|AETNA [101529]|2796.03||||2796.03|1258.21|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMBETTER [2930]|AMBETTER [293000]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2796.03||||2796.03|1398.02|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2796.03||||2796.03|1118.41|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2796.03||||2796.03|1118.41|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2796.03||||2796.03|1314.13|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2796.03||||2796.03|1146.37|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA PPO [126025]|2796.03||||2796.03|1118.41|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2796.03||||2796.03|1398.02|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2796.03||||2796.03|1258.21|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2796.03||||2796.03|1258.21|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|Self-pay|Self-pay|2796.03||||2796.03|559.21|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|TML [1980]|TML [198000]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2796.03||||2796.03|391.44|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UNICARE [2040]|UNICARE [204000]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2796.03||||2796.03|0|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WEB TPA [2115]|WEB TPA [211500]|2796.03||||2796.03|1929.26|1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2796.03||||2796.03||1929.26|391.44
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TML WC [212537]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|2796.03||||2796.03|1258.21|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMBETTER [2930]|AMBETTER [293000]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2796.03||||2796.03|1398.02|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2796.03||||2796.03|1118.41|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2796.03||||2796.03|1118.41|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2796.03||||2796.03|1314.13|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2796.03||||2796.03|1146.37|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA PPO [126025]|2796.03||||2796.03|1118.41|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2796.03||||2796.03|1398.02|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2796.03||||2796.03|1258.21|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2796.03||||2796.03|1258.21|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|2796.03||||2796.03|559.21|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|TML [1980]|TML [198000]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2796.03||||2796.03|391.44|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNICARE [2040]|UNICARE [204000]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2796.03||||2796.03|0|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WEB TPA [2115]|WEB TPA [211500]|2796.03||||2796.03|1929.26|1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2796.03||||2796.03||1929.26|391.44
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TML WC [212537]|2796.03||||2796.03|0|1929.26|391.44
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AARP [1000]|AARP [100000]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AETNA [1015]|AETNA [101529]|4.95||||4.95|2.23|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AMBETTER [2930]|AMBETTER [293000]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.95||||4.95|2.48|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.95||||4.95|1.98|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.95||||4.95|1.98|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.95||||4.95|2.33|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.95||||4.95|2.03|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.95||||4.95|1.98|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.95||||4.95|2.48|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.95||||4.95|2.23|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.95||||4.95|2.23|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|Self-pay|Self-pay|4.95||||4.95|0.99|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|TML [1980]|TML [198000]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.95||||4.95|0.69|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UNICARE [2040]|UNICARE [204000]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.95||||4.95|0|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WEB TPA [2115]|WEB TPA [211500]|4.95||||4.95|3.42|3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.95||||4.95||3.42|0.69
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.95||||4.95|0|3.42|0.69
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.36||||0.36|0.16|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.36||||0.36|0.18|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.36||||0.36|0.14|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.36||||0.36|0.14|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.36||||0.36|0.17|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.36||||0.36|0.15|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.36||||0.36|0.14|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.36||||0.36|0.18|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.36||||0.36|0.16|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.36||||0.36|0.16|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.36||||0.36|0.07|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.36||||0.36|0.05|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.36||||0.36|0|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.36||||0.36|0.25|0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.36||||0.36||0.25|0.05
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.36||||0.36|0|0.25|0.05
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|4.66||||4.66|2.1|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.66||||4.66|2.33|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.66||||4.66|1.86|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.66||||4.66|1.86|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.66||||4.66|2.19|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.66||||4.66|1.91|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|4.66||||4.66|1.86|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.66||||4.66|2.33|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.66||||4.66|2.1|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.66||||4.66|2.1|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|4.66||||4.66|0.93|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.66||||4.66|0.65|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.66||||4.66|0|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|4.66||||4.66|3.22|3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.66||||4.66||3.22|0.65
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|4.66||||4.66|0|3.22|0.65
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|625.68||||625.68|281.56|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|625.68||||625.68|312.84|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|625.68||||625.68|250.27|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|625.68||||625.68|250.27|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|625.68||||625.68|294.07|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|625.68||||625.68|256.53|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|625.68||||625.68|250.27|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|625.68||||625.68|312.84|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|625.68||||625.68|281.56|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|625.68||||625.68|281.56|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|625.68||||625.68|125.14|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|625.68||||625.68|87.6|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|625.68||||625.68|0|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|625.68||||625.68|431.72|431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|625.68||||625.68||431.72|87.6
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|625.68||||625.68|0|431.72|87.6
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|57.09||||57.09|25.69|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|57.09||||57.09|28.55|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.09||||57.09|22.84|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.09||||57.09|22.84|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.09||||57.09|26.83|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|57.09||||57.09|23.41|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|57.09||||57.09|22.84|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|57.09||||57.09|28.55|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.09||||57.09|25.69|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.09||||57.09|25.69|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|57.09||||57.09|11.42|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.09||||57.09|7.99|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.09||||57.09|0|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|57.09||||57.09|39.39|39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.09||||57.09||39.39|7.99
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|57.09||||57.09|0|39.39|7.99
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|11853.6||||11853.6|5334.12|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11853.6||||11853.6|5926.8|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11853.6||||11853.6|4741.44|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11853.6||||11853.6|4741.44|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11853.6||||11853.6|5571.19|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11853.6||||11853.6|4859.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|11853.6||||11853.6|5926.8|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11853.6||||11853.6|5926.8|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11853.6||||11853.6|5334.12|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11853.6||||11853.6|5334.12|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|11853.6||||11853.6|2370.72|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11853.6||||11853.6|1659.5|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|11853.6||||11853.6|8178.98|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11853.6||||11853.6||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|11853.6||||11853.6|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|23707.2||||23707.2|10668.24|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMBETTER [2930]|AMBETTER [293000]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23707.2||||23707.2|11853.6|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23707.2||||23707.2|9482.88|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23707.2||||23707.2|9482.88|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23707.2||||23707.2|11142.38|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23707.2||||23707.2|9719.95|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA PPO [126025]|23707.2||||23707.2|11853.6|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23707.2||||23707.2|11853.6|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23707.2||||23707.2|10668.24|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23707.2||||23707.2|10668.24|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|23707.2||||23707.2|4741.44|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|TML [1980]|TML [198000]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23707.2||||23707.2|3319.01|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNICARE [2040]|UNICARE [204000]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23707.2||||23707.2|0|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WEB TPA [2115]|WEB TPA [211500]|23707.2||||23707.2|16357.97|16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23707.2||||23707.2||16357.97|1659.5
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TML WC [212537]|23707.2||||23707.2|0|16357.97|1659.5
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AARP [1000]|AARP [100000]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AETNA [1015]|AETNA [101529]|85.14||||85.14|38.31|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMBETTER [2930]|AMBETTER [293000]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|85.14||||85.14|42.57|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85.14||||85.14|34.06|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85.14||||85.14|34.06|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85.14||||85.14|40.02|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|85.14||||85.14|34.91|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA [1260]|CIGNA PPO [126025]|85.14||||85.14|34.06|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|85.14||||85.14|42.57|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85.14||||85.14|38.31|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85.14||||85.14|38.31|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|Self-pay|Self-pay|85.14||||85.14|17.03|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|TML [1980]|TML [198000]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85.14||||85.14|11.92|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNICARE [2040]|UNICARE [204000]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85.14||||85.14|0|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WEB TPA [2115]|WEB TPA [211500]|85.14||||85.14|58.75|58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85.14||||85.14||58.75|11.92
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WORKER'S COMP [2125]|TML WC [212537]|85.14||||85.14|0|58.75|11.92
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|17.82|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|15.84|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|15.84|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|18.61|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|16.24|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|17.82|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|17.82|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|39.6||||39.6|7.92|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|5.54|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|0|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6||27.32|5.54
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|0|27.32|5.54
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|161.78||||161.78|72.8|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|161.78||||161.78|80.89|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161.78||||161.78|64.71|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161.78||||161.78|64.71|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161.78||||161.78|76.04|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|161.78||||161.78|66.33|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|161.78||||161.78|64.71|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|161.78||||161.78|80.89|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161.78||||161.78|72.8|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161.78||||161.78|72.8|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|161.78||||161.78|32.36|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161.78||||161.78|22.65|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161.78||||161.78|0|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|161.78||||161.78|111.63|111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161.78||||161.78||111.63|22.65
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|161.78||||161.78|0|111.63|22.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AARP [1000]|AARP [100000]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|AETNA [101529]|47.52||||47.52|21.38|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMBETTER [2930]|AMBETTER [293000]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.52||||47.52|23.76|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.52||||47.52|19.01|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.52||||47.52|19.01|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.52||||47.52|22.33|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|47.52||||47.52|19.48|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA PPO [126025]|47.52||||47.52|19.01|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.52||||47.52|23.76|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.52||||47.52|21.38|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.52||||47.52|21.38|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|Self-pay|Self-pay|47.52||||47.52|9.5|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|TML [1980]|TML [198000]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.52||||47.52|6.65|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNICARE [2040]|UNICARE [204000]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.52||||47.52|0|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WEB TPA [2115]|WEB TPA [211500]|47.52||||47.52|32.79|32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.52||||47.52||32.79|6.65
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|TML WC [212537]|47.52||||47.52|0|32.79|6.65
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|323.56||||323.56|145.6|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|323.56||||323.56|161.78|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|323.56||||323.56|129.42|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|323.56||||323.56|129.42|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|323.56||||323.56|152.07|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|323.56||||323.56|132.66|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|323.56||||323.56|129.42|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|323.56||||323.56|161.78|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323.56||||323.56|145.6|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|323.56||||323.56|145.6|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|323.56||||323.56|64.71|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|323.56||||323.56|45.3|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|323.56||||323.56|0|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|323.56||||323.56|223.26|223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|323.56||||323.56||223.26|45.3
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|323.56||||323.56|0|223.26|45.3
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.02||||6.02|2.71|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.02||||6.02|3.01|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.02||||6.02|2.41|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.02||||6.02|2.41|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.02||||6.02|2.83|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.02||||6.02|2.47|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.02||||6.02|2.41|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.02||||6.02|3.01|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.02||||6.02|2.71|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.02||||6.02|2.71|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.02||||6.02|1.2|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.02||||6.02|0.84|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.02||||6.02|0|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.02||||6.02|4.15|4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.02||||6.02||4.15|0.84
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.02||||6.02|0|4.15|0.84
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AARP [1000]|AARP [100000]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|71.28|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|63.36|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|63.36|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|74.45|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|64.94|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|71.28|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|71.28|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|Self-pay|Self-pay|158.4||||158.4|31.68|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|22.18|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|0|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4||109.3|22.18
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|0|109.3|22.18
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.27||||4.27|1.92|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.27||||4.27|2.14|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.27||||4.27|1.71|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.27||||4.27|1.71|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.27||||4.27|2.01|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.27||||4.27|1.75|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.27||||4.27|1.71|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.27||||4.27|2.14|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.27||||4.27|1.92|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.27||||4.27|1.92|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|4.27||||4.27|0.85|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.27||||4.27|0.6|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.27||||4.27|0|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.27||||4.27|2.95|2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.27||||4.27||2.95|0.6
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.27||||4.27|0|2.95|0.6
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|396||||396|178.2|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMBETTER [2930]|AMBETTER [293000]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|396||||396|198|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|158.4|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|158.4|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|186.12|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|396||||396|162.36|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA PPO [126025]|396||||396|158.4|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|396||||396|198|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|178.2|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|178.2|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|Self-pay|Self-pay|396||||396|79.2|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|TML [1980]|TML [198000]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|55.44|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNICARE [2040]|UNICARE [204000]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396|0|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WEB TPA [2115]|WEB TPA [211500]|396||||396|273.24|273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396||273.24|55.44
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TML WC [212537]|396||||396|0|273.24|55.44
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AARP [1000]|AARP [100000]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA [1015]|AETNA [101529]|89.57||||89.57|40.31|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMBETTER [2930]|AMBETTER [293000]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.57||||89.57|44.79|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.57||||89.57|35.83|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.57||||89.57|35.83|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.57||||89.57|42.1|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|89.57||||89.57|36.72|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA [1260]|CIGNA PPO [126025]|89.57||||89.57|35.83|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.57||||89.57|44.79|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.57||||89.57|40.31|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.57||||89.57|40.31|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|Self-pay|Self-pay|89.57||||89.57|17.91|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|TML [1980]|TML [198000]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.57||||89.57|12.54|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNICARE [2040]|UNICARE [204000]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.57||||89.57|0|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WEB TPA [2115]|WEB TPA [211500]|89.57||||89.57|61.8|61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89.57||||89.57||61.8|12.54
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WORKER'S COMP [2125]|TML WC [212537]|89.57||||89.57|0|61.8|12.54
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|178.72||||178.72|80.42|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|178.72||||178.72|89.36|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178.72||||178.72|71.49|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178.72||||178.72|71.49|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178.72||||178.72|84|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|178.72||||178.72|73.28|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|178.72||||178.72|71.49|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|178.72||||178.72|89.36|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178.72||||178.72|80.42|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178.72||||178.72|80.42|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|Self-pay|Self-pay|178.72||||178.72|35.74|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|TML [1980]|TML [198000]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178.72||||178.72|25.02|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178.72||||178.72|0|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|178.72||||178.72|123.32|123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|178.72||||178.72||123.32|25.02
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|178.72||||178.72|0|123.32|25.02
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|213.61||||213.61|96.12|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|213.61||||213.61|106.81|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.61||||213.61|85.44|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.61||||213.61|85.44|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.61||||213.61|100.4|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|213.61||||213.61|87.58|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|213.61||||213.61|85.44|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|213.61||||213.61|106.81|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.61||||213.61|96.12|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.61||||213.61|96.12|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|213.61||||213.61|42.72|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.61||||213.61|29.91|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.61||||213.61|0|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|213.61||||213.61|147.39|147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.61||||213.61||147.39|29.91
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|213.61||||213.61|0|147.39|29.91
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.67||||17.67|7.95|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.67||||17.67|8.84|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.67||||17.67|7.07|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.67||||17.67|7.07|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.67||||17.67|8.3|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.67||||17.67|7.24|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.67||||17.67|7.07|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.67||||17.67|8.84|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.67||||17.67|7.95|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.67||||17.67|7.95|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|17.67||||17.67|3.53|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.67||||17.67|2.47|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.67||||17.67|0|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.67||||17.67|12.19|12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.67||||17.67||12.19|2.47
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.67||||17.67|0|12.19|2.47
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|16.25||||16.25|7.31|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.25||||16.25|8.13|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.25||||16.25|6.5|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.25||||16.25|6.5|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.25||||16.25|7.64|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.25||||16.25|6.66|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|16.25||||16.25|6.5|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.25||||16.25|8.13|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.25||||16.25|7.31|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.25||||16.25|7.31|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|Self-pay|Self-pay|16.25||||16.25|3.25|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.25||||16.25|2.28|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.25||||16.25|0|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|16.25||||16.25|11.21|11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.25||||16.25||11.21|2.28
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|16.25||||16.25|0|11.21|2.28
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|128||||128|57.6|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128||||128|64|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128||||128|51.2|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128||||128|51.2|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128||||128|60.16|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128||||128|52.48|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|128||||128|51.2|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128||||128|64|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128||||128|57.6|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128||||128|57.6|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|128||||128|25.6|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128||||128|17.92|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128||||128|0|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|128||||128|88.32|88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128||||128||88.32|17.92
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|128||||128|0|88.32|17.92
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AARP [1000]|AARP [100000]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA [1015]|AETNA [101529]|216.71||||216.71|97.52|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMBETTER [2930]|AMBETTER [293000]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.71||||216.71|108.36|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.71||||216.71|86.68|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.71||||216.71|86.68|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.71||||216.71|101.85|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.71||||216.71|88.85|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA [1260]|CIGNA PPO [126025]|216.71||||216.71|86.68|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.71||||216.71|108.36|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.71||||216.71|97.52|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.71||||216.71|97.52|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|Self-pay|Self-pay|216.71||||216.71|43.34|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|TML [1980]|TML [198000]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.71||||216.71|30.34|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNICARE [2040]|UNICARE [204000]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.71||||216.71|0|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WEB TPA [2115]|WEB TPA [211500]|216.71||||216.71|149.53|149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216.71||||216.71||149.53|30.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WORKER'S COMP [2125]|TML WC [212537]|216.71||||216.71|0|149.53|30.34
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|90.85||||90.85|40.88|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.85||||90.85|45.43|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.85||||90.85|36.34|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.85||||90.85|36.34|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.85||||90.85|42.7|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.85||||90.85|37.25|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.85||||90.85|36.34|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.85||||90.85|45.43|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.85||||90.85|40.88|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.85||||90.85|40.88|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|Self-pay|Self-pay|90.85||||90.85|18.17|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|TML [1980]|TML [198000]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.85||||90.85|12.72|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.85||||90.85|0|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.85||||90.85|62.69|62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.85||||90.85||62.69|12.72
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.85||||90.85|0|62.69|12.72
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.39||||1.39|0.63|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.39||||1.39|0.7|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.39||||1.39|0.56|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.39||||1.39|0.56|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.39||||1.39|0.65|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.39||||1.39|0.57|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.39||||1.39|0.56|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.39||||1.39|0.7|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.39||||1.39|0.63|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.39||||1.39|0.63|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|Self-pay|Self-pay|1.39||||1.39|0.28|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|TML [1980]|TML [198000]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.39||||1.39|0.19|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.39||||1.39|0|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.39||||1.39|0.96|0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.39||||1.39||0.96|0.19
11050|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.39||||1.39|0|0.96|0.19
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.6||||17.6|7.92|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.6||||17.6|8.8|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.6||||17.6|7.04|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.6||||17.6|7.04|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.6||||17.6|8.27|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.6||||17.6|7.22|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.6||||17.6|7.04|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.6||||17.6|8.8|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.6||||17.6|7.92|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.6||||17.6|7.92|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|Self-pay|Self-pay|17.6||||17.6|3.52|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.6||||17.6|2.46|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.6||||17.6|0|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.6||||17.6|12.14|12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.6||||17.6||12.14|2.46
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.6||||17.6|0|12.14|2.46
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|64.68||||64.68|29.11|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.68||||64.68|32.34|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.68||||64.68|25.87|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.68||||64.68|25.87|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.68||||64.68|30.4|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.68||||64.68|26.52|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|64.68||||64.68|25.87|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.68||||64.68|32.34|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.68||||64.68|29.11|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.68||||64.68|29.11|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|64.68||||64.68|12.94|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.68||||64.68|9.06|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.68||||64.68|0|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|64.68||||64.68|44.63|44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.68||||64.68||44.63|9.06
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|64.68||||64.68|0|44.63|9.06
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|17.82||||17.82|8.02|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.82||||17.82|8.91|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.82||||17.82|7.13|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.82||||17.82|7.13|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.82||||17.82|8.38|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.82||||17.82|7.31|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|17.82||||17.82|7.13|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.82||||17.82|8.91|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.82||||17.82|8.02|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.82||||17.82|8.02|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|17.82||||17.82|3.56|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.82||||17.82|2.49|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.82||||17.82|0|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|17.82||||17.82|12.3|12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.82||||17.82||12.3|2.49
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|17.82||||17.82|0|12.3|2.49
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|118.8||||118.8|53.46|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.8||||118.8|59.4|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.8||||118.8|47.52|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.8||||118.8|47.52|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.8||||118.8|55.84|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.8||||118.8|48.71|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|118.8||||118.8|47.52|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.8||||118.8|59.4|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.8||||118.8|53.46|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.8||||118.8|53.46|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|118.8||||118.8|23.76|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|TML [1980]|TML [198000]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.8||||118.8|16.63|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNICARE [2040]|UNICARE [204000]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.8||||118.8|0|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|118.8||||118.8|81.97|81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.8||||118.8||81.97|16.63
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|118.8||||118.8|0|81.97|16.63
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|28.24||||28.24|12.71|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.24||||28.24|14.12|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.24||||28.24|11.3|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.24||||28.24|11.3|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.24||||28.24|13.27|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28.24||||28.24|11.58|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|28.24||||28.24|11.3|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.24||||28.24|14.12|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.24||||28.24|12.71|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.24||||28.24|12.71|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|28.24||||28.24|5.65|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.24||||28.24|3.95|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.24||||28.24|0|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|28.24||||28.24|19.49|19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.24||||28.24||19.49|3.95
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|28.24||||28.24|0|19.49|3.95
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AARP [1000]|AARP [100000]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.41||||6.41|2.88|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.41||||6.41|3.21|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.41||||6.41|2.56|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.41||||6.41|2.56|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.41||||6.41|3.01|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.41||||6.41|2.63|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.41||||6.41|2.56|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.41||||6.41|3.21|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.41||||6.41|2.88|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.41||||6.41|2.88|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|Self-pay|Self-pay|6.41||||6.41|1.28|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|TML [1980]|TML [198000]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.41||||6.41|0.9|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.41||||6.41|0|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.41||||6.41|4.42|4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.41||||6.41||4.42|0.9
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.41||||6.41|0|4.42|0.9
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|926.64||||926.64|416.99|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMBETTER [2930]|AMBETTER [293000]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|926.64||||926.64|463.32|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|926.64||||926.64|370.66|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|926.64||||926.64|370.66|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|926.64||||926.64|435.52|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|926.64||||926.64|379.92|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|926.64||||926.64|370.66|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|926.64||||926.64|463.32|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|926.64||||926.64|416.99|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|926.64||||926.64|416.99|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|926.64||||926.64|185.33|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|TML [1980]|TML [198000]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|926.64||||926.64|129.73|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNICARE [2040]|UNICARE [204000]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|926.64||||926.64|0|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WEB TPA [2115]|WEB TPA [211500]|926.64||||926.64|639.38|639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|926.64||||926.64||639.38|129.73
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|926.64||||926.64|0|639.38|129.73
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.3||||9.3|4.19|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.3||||9.3|4.65|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|3.72|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|3.72|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|4.37|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.3||||9.3|3.81|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.3||||9.3|3.72|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.3||||9.3|4.65|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|4.19|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|4.19|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|9.3||||9.3|1.86|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|1.3|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3|0|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.3||||9.3|6.42|6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||6.42|1.3
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.3||||9.3|0|6.42|1.3
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AARP [1000]|AARP [100000]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AETNA [1015]|AETNA [101529]|45.15||||45.15|20.32|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMBETTER [2930]|AMBETTER [293000]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|45.15||||45.15|22.58|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.15||||45.15|18.06|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.15||||45.15|18.06|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.15||||45.15|21.22|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|45.15||||45.15|18.51|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA [1260]|CIGNA PPO [126025]|45.15||||45.15|18.06|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|45.15||||45.15|22.58|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.15||||45.15|20.32|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.15||||45.15|20.32|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|Self-pay|Self-pay|45.15||||45.15|9.03|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|TML [1980]|TML [198000]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.15||||45.15|6.32|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UNICARE [2040]|UNICARE [204000]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.15||||45.15|0|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WEB TPA [2115]|WEB TPA [211500]|45.15||||45.15|31.15|31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.15||||45.15||31.15|6.32
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WORKER'S COMP [2125]|TML WC [212537]|45.15||||45.15|0|31.15|6.32
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.19||||7.19|3.24|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.19||||7.19|3.6|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.19||||7.19|2.88|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.19||||7.19|2.88|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.19||||7.19|3.38|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.19||||7.19|2.95|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.19||||7.19|2.88|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.19||||7.19|3.6|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.19||||7.19|3.24|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.19||||7.19|3.24|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|7.19||||7.19|1.44|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.19||||7.19|1.01|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.19||||7.19|0|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.19||||7.19|4.96|4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.19||||7.19||4.96|1.01
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.19||||7.19|0|4.96|1.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|115.02||||115.02|51.76|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|115.02||||115.02|57.51|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|115.02||||115.02|46.01|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115.02||||115.02|46.01|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|115.02||||115.02|54.06|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|115.02||||115.02|47.16|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|115.02||||115.02|46.01|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|115.02||||115.02|57.51|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115.02||||115.02|51.76|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115.02||||115.02|51.76|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|115.02||||115.02|23|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|115.02||||115.02|16.1|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115.02||||115.02|0|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|115.02||||115.02|79.36|79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|115.02||||115.02||79.36|16.1
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|115.02||||115.02|0|79.36|16.1
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|128.68||||128.68|57.91|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.68||||128.68|64.34|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.68||||128.68|51.47|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.68||||128.68|51.47|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.68||||128.68|60.48|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.68||||128.68|52.76|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|128.68||||128.68|51.47|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.68||||128.68|64.34|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.68||||128.68|57.91|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.68||||128.68|57.91|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|128.68||||128.68|25.74|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.68||||128.68|18.02|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.68||||128.68|0|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|128.68||||128.68|88.79|88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.68||||128.68||88.79|18.02
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|128.68||||128.68|0|88.79|18.02
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.58||||3.58|1.61|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.58||||3.58|1.79|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.58||||3.58|1.43|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.58||||3.58|1.43|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.58||||3.58|1.68|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.58||||3.58|1.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.58||||3.58|1.43|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.58||||3.58|1.79|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.58||||3.58|1.61|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.58||||3.58|1.61|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|Self-pay|Self-pay|3.58||||3.58|0.72|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.58||||3.58|0.5|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.58||||3.58|0|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.58||||3.58|2.47|2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.58||||3.58||2.47|0.5
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.58||||3.58|0|2.47|0.5
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|4.88||||4.88|2.2|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.88||||4.88|2.44|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.88||||4.88|1.95|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.88||||4.88|1.95|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.88||||4.88|2.29|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.88||||4.88|2|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|4.88||||4.88|1.95|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.88||||4.88|2.44|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.88||||4.88|2.2|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.88||||4.88|2.2|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|4.88||||4.88|0.98|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.88||||4.88|0.68|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.88||||4.88|0|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|4.88||||4.88|3.37|3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.88||||4.88||3.37|0.68
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|4.88||||4.88|0|3.37|0.68
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.24||||17.24|7.76|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.24||||17.24|8.62|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.24||||17.24|6.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.24||||17.24|6.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.24||||17.24|8.1|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.24||||17.24|7.07|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.24||||17.24|6.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.24||||17.24|8.62|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.24||||17.24|7.76|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.24||||17.24|7.76|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|Self-pay|Self-pay|17.24||||17.24|3.45|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|TML [1980]|TML [198000]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.24||||17.24|2.41|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.24||||17.24|0|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.24||||17.24|11.9|11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.24||||17.24||11.9|2.41
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.24||||17.24|0|11.9|2.41
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|273.15||||273.15|122.92|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|273.15||||273.15|136.58|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|273.15||||273.15|109.26|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|273.15||||273.15|109.26|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|273.15||||273.15|128.38|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|273.15||||273.15|111.99|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|273.15||||273.15|109.26|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|273.15||||273.15|136.58|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|273.15||||273.15|122.92|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|273.15||||273.15|122.92|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|273.15||||273.15|54.63|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|273.15||||273.15|38.24|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|273.15||||273.15|0|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|273.15||||273.15|188.47|188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|273.15||||273.15||188.47|38.24
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|273.15||||273.15|0|188.47|38.24
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|2019.6||||2019.6|908.82|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMBETTER [2930]|AMBETTER [293000]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2019.6||||2019.6|1009.8|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2019.6||||2019.6|807.84|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2019.6||||2019.6|807.84|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2019.6||||2019.6|949.21|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2019.6||||2019.6|828.04|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA PPO [126025]|2019.6||||2019.6|807.84|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2019.6||||2019.6|1009.8|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2019.6||||2019.6|908.82|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2019.6||||2019.6|908.82|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|2019.6||||2019.6|403.92|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|TML [1980]|TML [198000]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2019.6||||2019.6|282.74|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNICARE [2040]|UNICARE [204000]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2019.6||||2019.6|0|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WEB TPA [2115]|WEB TPA [211500]|2019.6||||2019.6|1393.52|1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2019.6||||2019.6||1393.52|282.74
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TML WC [212537]|2019.6||||2019.6|0|1393.52|282.74
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|13.05||||13.05|5.87|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.05||||13.05|6.53|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.05||||13.05|5.22|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.05||||13.05|5.22|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.05||||13.05|6.13|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.05||||13.05|5.35|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|13.05||||13.05|5.22|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.05||||13.05|6.53|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.05||||13.05|5.87|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.05||||13.05|5.87|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|13.05||||13.05|2.61|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.05||||13.05|1.83|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.05||||13.05|0|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|13.05||||13.05|9|9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.05||||13.05||9|1.83
11292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|13.05||||13.05|0|9|1.83
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|46.07||||46.07|20.73|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.07||||46.07|23.04|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.07||||46.07|18.43|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.07||||46.07|18.43|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.07||||46.07|21.65|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.07||||46.07|18.89|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|46.07||||46.07|18.43|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.07||||46.07|23.04|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.07||||46.07|20.73|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.07||||46.07|20.73|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|Self-pay|Self-pay|46.07||||46.07|9.21|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.07||||46.07|6.45|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.07||||46.07|0|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|46.07||||46.07|31.79|31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.07||||46.07||31.79|6.45
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|46.07||||46.07|0|31.79|6.45
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AARP [1000]|AARP [100000]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA [1015]|AETNA [101529]|15.84||||15.84|7.13|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.84||||15.84|7.92|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.84||||15.84|6.34|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.84||||15.84|6.34|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.84||||15.84|7.44|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.84||||15.84|6.49|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|15.84||||15.84|6.34|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.84||||15.84|7.92|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.84||||15.84|7.13|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.84||||15.84|7.13|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|Self-pay|Self-pay|15.84||||15.84|3.17|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|TML [1980]|TML [198000]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.84||||15.84|2.22|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNICARE [2040]|UNICARE [204000]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.84||||15.84|0|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|15.84||||15.84|10.93|10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.84||||15.84||10.93|2.22
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|15.84||||15.84|0|10.93|2.22
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.42||||19.42|8.74|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.42||||19.42|9.71|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.42||||19.42|7.77|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.42||||19.42|7.77|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.42||||19.42|9.13|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.42||||19.42|7.96|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.42||||19.42|7.77|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.42||||19.42|9.71|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.42||||19.42|8.74|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.42||||19.42|8.74|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|19.42||||19.42|3.88|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.42||||19.42|2.72|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.42||||19.42|0|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.42||||19.42|13.4|13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.42||||19.42||13.4|2.72
11340|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELEGILINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.42||||19.42|0|13.4|2.72
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|244.2||||244.2|109.89|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244.2||||244.2|122.1|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.2||||244.2|97.68|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.2||||244.2|97.68|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.2||||244.2|114.77|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244.2||||244.2|100.12|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|244.2||||244.2|97.68|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244.2||||244.2|122.1|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.2||||244.2|109.89|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.2||||244.2|109.89|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|Self-pay|Self-pay|244.2||||244.2|48.84|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|TML [1980]|TML [198000]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.2||||244.2|34.19|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.2||||244.2|0|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|244.2||||244.2|168.5|168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.2||||244.2||168.5|34.19
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|244.2||||244.2|0|168.5|34.19
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.47||||0.47|0.21|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.47||||0.47|0.24|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.47||||0.47|0.19|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.47||||0.47|0.19|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.47||||0.47|0.22|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.47||||0.47|0.19|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.47||||0.47|0.19|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.47||||0.47|0.24|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.47||||0.47|0.21|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.47||||0.47|0.21|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|Self-pay|Self-pay|0.47||||0.47|0.09|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.47||||0.47|0.07|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.47||||0.47|0|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.47||||0.47|0.32|0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.47||||0.47||0.32|0.07
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.47||||0.47|0|0.32|0.07
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.18||||5.18|2.33|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.18||||5.18|2.59|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.18||||5.18|2.07|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.18||||5.18|2.07|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.18||||5.18|2.43|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.18||||5.18|2.12|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.18||||5.18|2.07|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.18||||5.18|2.59|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.18||||5.18|2.33|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.18||||5.18|2.33|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|5.18||||5.18|1.04|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.18||||5.18|0.73|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.18||||5.18|0|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.18||||5.18|3.57|3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.18||||5.18||3.57|0.73
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.18||||5.18|0|3.57|0.73
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|592.42||||592.42|266.59|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|592.42||||592.42|296.21|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|592.42||||592.42|236.97|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|592.42||||592.42|236.97|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|592.42||||592.42|278.44|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|592.42||||592.42|242.89|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|592.42||||592.42|236.97|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|592.42||||592.42|296.21|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|592.42||||592.42|266.59|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|592.42||||592.42|266.59|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|592.42||||592.42|118.48|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|592.42||||592.42|82.94|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|592.42||||592.42|0|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|592.42||||592.42|408.77|408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|592.42||||592.42||408.77|82.94
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|592.42||||592.42|0|408.77|82.94
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AARP [1000]|AARP [100000]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA [1015]|AETNA [101529]|8.39||||8.39|3.78|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMBETTER [2930]|AMBETTER [293000]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.39||||8.39|4.2|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.39||||8.39|3.36|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.39||||8.39|3.36|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.39||||8.39|3.94|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.39||||8.39|3.44|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA [1260]|CIGNA PPO [126025]|8.39||||8.39|3.36|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.39||||8.39|4.2|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.39||||8.39|3.78|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.39||||8.39|3.78|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|Self-pay|Self-pay|8.39||||8.39|1.68|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|TML [1980]|TML [198000]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.39||||8.39|1.17|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNICARE [2040]|UNICARE [204000]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.39||||8.39|0|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WEB TPA [2115]|WEB TPA [211500]|8.39||||8.39|5.79|5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.39||||8.39||5.79|1.17
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WORKER'S COMP [2125]|TML WC [212537]|8.39||||8.39|0|5.79|1.17
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|168.56||||168.56|75.85|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|168.56||||168.56|84.28|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168.56||||168.56|67.42|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168.56||||168.56|67.42|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168.56||||168.56|79.22|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|168.56||||168.56|69.11|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|168.56||||168.56|67.42|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|168.56||||168.56|84.28|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168.56||||168.56|75.85|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168.56||||168.56|75.85|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|168.56||||168.56|33.71|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168.56||||168.56|23.6|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168.56||||168.56|0|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|168.56||||168.56|116.31|116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168.56||||168.56||116.31|23.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|168.56||||168.56|0|116.31|23.6
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|580.28||||580.28|261.13|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.28||||580.28|290.14|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580.28||||580.28|232.11|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580.28||||580.28|232.11|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580.28||||580.28|272.73|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.28||||580.28|237.91|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|580.28||||580.28|232.11|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.28||||580.28|290.14|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.28||||580.28|261.13|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.28||||580.28|261.13|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|580.28||||580.28|116.06|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580.28||||580.28|81.24|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.28||||580.28|0|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|580.28||||580.28|400.39|400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580.28||||580.28||400.39|81.24
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|580.28||||580.28|0|400.39|81.24
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|68.24|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|68.24|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|59.53|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|59.53|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|65.34|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|145.2||||145.2|29.04|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|145.2||||145.2|29.04|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TML [1980]|TML [198000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TML [1980]|TML [198000]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|20.33|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|20.33|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2||100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2|0|100.19|20.33
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2|0|100.19|20.33
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|16.8||||16.8|7.56|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.8||||16.8|8.4|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.8||||16.8|6.72|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.8||||16.8|6.72|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.8||||16.8|7.9|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.8||||16.8|6.89|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.8||||16.8|6.72|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.8||||16.8|8.4|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.8||||16.8|7.56|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.8||||16.8|7.56|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|Self-pay|Self-pay|16.8||||16.8|3.36|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|TML [1980]|TML [198000]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.8||||16.8|2.35|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.8||||16.8|0|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.8||||16.8|11.59|11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.8||||16.8||11.59|2.35
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|16.8||||16.8|0|11.59|2.35
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|68.45||||68.45|30.8|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|68.45||||68.45|34.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.45||||68.45|27.38|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.45||||68.45|27.38|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.45||||68.45|32.17|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|68.45||||68.45|28.06|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|68.45||||68.45|27.38|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|68.45||||68.45|34.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.45||||68.45|30.8|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.45||||68.45|30.8|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|68.45||||68.45|13.69|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.45||||68.45|9.58|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.45||||68.45|0|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|68.45||||68.45|47.23|47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.45||||68.45||47.23|9.58
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|68.45||||68.45|0|47.23|9.58
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|1.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.18||||4.18|1.67|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|1.67|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.18||||4.18|1.96|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|1.71|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|1.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|1.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.18||||4.18|0.59|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18|0|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.18||||4.18||2.88|0.59
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18|0|2.88|0.59
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|39.76||||39.76|17.89|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.76||||39.76|19.88|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.76||||39.76|15.9|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.76||||39.76|15.9|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.76||||39.76|18.69|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.76||||39.76|16.3|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|39.76||||39.76|15.9|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.76||||39.76|19.88|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.76||||39.76|17.89|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.76||||39.76|17.89|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|39.76||||39.76|7.95|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.76||||39.76|5.57|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.76||||39.76|0|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|39.76||||39.76|27.43|27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.76||||39.76||27.43|5.57
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|39.76||||39.76|0|27.43|5.57
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|39.34||||39.34|17.7|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.34||||39.34|19.67|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.34||||39.34|15.74|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.34||||39.34|15.74|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.34||||39.34|18.49|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.34||||39.34|16.13|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|39.34||||39.34|15.74|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.34||||39.34|19.67|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.34||||39.34|17.7|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.34||||39.34|17.7|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|Self-pay|Self-pay|39.34||||39.34|7.87|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|TML [1980]|TML [198000]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.34||||39.34|5.51|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.34||||39.34|0|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|39.34||||39.34|27.14|27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.34||||39.34||27.14|5.51
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|39.34||||39.34|0|27.14|5.51
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|114.71||||114.71|51.62|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|114.71||||114.71|57.36|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114.71||||114.71|45.88|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114.71||||114.71|45.88|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114.71||||114.71|53.91|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|114.71||||114.71|47.03|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|114.71||||114.71|45.88|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|114.71||||114.71|57.36|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114.71||||114.71|51.62|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114.71||||114.71|51.62|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|114.71||||114.71|22.94|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|TML [1980]|TML [198000]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114.71||||114.71|16.06|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114.71||||114.71|0|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|114.71||||114.71|79.15|79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114.71||||114.71||79.15|16.06
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|114.71||||114.71|0|79.15|16.06
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AARP [1000]|AARP [100000]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AETNA [1015]|AETNA [101529]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1338.48||||1338.48|669.24|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1338.48||||1338.48|629.09|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1338.48||||1338.48|548.78|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1338.48||||1338.48|669.24|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|Self-pay|Self-pay|1338.48||||1338.48|267.7|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|TML [1980]|TML [198000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1338.48||||1338.48|187.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UNICARE [2040]|UNICARE [204000]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1338.48||||1338.48|669.24|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1338.48||||1338.48|629.09|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1338.48||||1338.48|548.78|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1338.48||||1338.48|535.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1338.48||||1338.48|669.24|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1338.48||||1338.48|602.32|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|1338.48||||1338.48|267.7|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|TML [1980]|TML [198000]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1338.48||||1338.48|187.39|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1338.48||||1338.48|0|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|1338.48||||1338.48|923.55|923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1338.48||||1338.48||923.55|187.39
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1338.48||||1338.48|0|923.55|187.39
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|78.6||||78.6|35.37|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|78.6||||78.6|39.3|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78.6||||78.6|31.44|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78.6||||78.6|31.44|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78.6||||78.6|36.94|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|78.6||||78.6|32.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|78.6||||78.6|31.44|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|78.6||||78.6|39.3|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.6||||78.6|35.37|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.6||||78.6|35.37|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|78.6||||78.6|15.72|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78.6||||78.6|11|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.6||||78.6|0|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|78.6||||78.6|54.23|54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78.6||||78.6||54.23|11
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|78.6||||78.6|0|54.23|11
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AARP [1000]|AARP [100000]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AETNA [1015]|AETNA [101529]|2805||||2805|1262.25|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMBETTER [2930]|AMBETTER [293000]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2805||||2805|1402.5|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2805||||2805|1122|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2805||||2805|1122|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2805||||2805|1318.35|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2805||||2805|1150.05|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA [1260]|CIGNA PPO [126025]|2805||||2805|1122|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|GROUP PENSION ADMIN [1450]|GPA [145000]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2805||||2805|1402.5|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2805||||2805|1262.25|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2805||||2805|1262.25|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|PHCS [1780]|PHCS MULTIPLAN [178000]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|Self-pay|Self-pay|2805||||2805|561|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|TML [1980]|TML [198000]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2805||||2805|392.7|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UNICARE [2040]|UNICARE [204000]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2805||||2805|0|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WEB TPA [2115]|WEB TPA [211500]|2805||||2805|1935.45|1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2805||||2805||1935.45|392.7
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WORKER'S COMP [2125]|TML WC [212537]|2805||||2805|0|1935.45|392.7
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AARP [1000]|AARP [100000]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA [1015]|AETNA [101529]|12.02||||12.02|5.41|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMBETTER [2930]|AMBETTER [293000]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.02||||12.02|6.01|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.02||||12.02|4.81|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.02||||12.02|4.81|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.02||||12.02|5.65|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.02||||12.02|4.93|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA [1260]|CIGNA PPO [126025]|12.02||||12.02|4.81|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.02||||12.02|6.01|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.02||||12.02|5.41|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.02||||12.02|5.41|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|Self-pay|Self-pay|12.02||||12.02|2.4|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|TML [1980]|TML [198000]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.02||||12.02|1.68|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNICARE [2040]|UNICARE [204000]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WEB TPA [2115]|WEB TPA [211500]|12.02||||12.02|8.29|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.02||||12.02||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WORKER'S COMP [2125]|TML WC [212537]|12.02||||12.02|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AARP [1000]|AARP [100000]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA [1015]|AETNA [101529]|17.16||||17.16|7.72|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMBETTER [2930]|AMBETTER [293000]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.16||||17.16|8.58|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.16||||17.16|6.86|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.16||||17.16|6.86|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.16||||17.16|8.07|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.16||||17.16|7.04|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA [1260]|CIGNA PPO [126025]|17.16||||17.16|6.86|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.16||||17.16|8.58|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.16||||17.16|7.72|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.16||||17.16|7.72|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|Self-pay|Self-pay|17.16||||17.16|3.43|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|TML [1980]|TML [198000]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.16||||17.16|2.4|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNICARE [2040]|UNICARE [204000]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.16||||17.16|0|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WEB TPA [2115]|WEB TPA [211500]|17.16||||17.16|11.84|11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.16||||17.16||11.84|1.68
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WORKER'S COMP [2125]|TML WC [212537]|17.16||||17.16|0|11.84|1.68
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AARP [1000]|AARP [100000]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AETNA [1015]|AETNA [101529]|5854.36||||5854.36|2634.46|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMBETTER [2930]|AMBETTER [293000]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5854.36||||5854.36|2927.18|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5854.36||||5854.36|2341.74|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5854.36||||5854.36|2341.74|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5854.36||||5854.36|2751.55|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5854.36||||5854.36|2400.29|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA [1260]|CIGNA PPO [126025]|5854.36||||5854.36|2341.74|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5854.36||||5854.36|2927.18|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5854.36||||5854.36|2634.46|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5854.36||||5854.36|2634.46|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|Self-pay|Self-pay|5854.36||||5854.36|1170.87|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|TML [1980]|TML [198000]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5854.36||||5854.36|819.61|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNICARE [2040]|UNICARE [204000]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5854.36||||5854.36|0|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WEB TPA [2115]|WEB TPA [211500]|5854.36||||5854.36|4039.51|4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5854.36||||5854.36||4039.51|819.61
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WORKER'S COMP [2125]|TML WC [212537]|5854.36||||5854.36|0|4039.51|819.61
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|20||||20|9|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20||||20|10|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|9.4|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20||||20|8.2|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20||||20|8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20||||20|10|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|9|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|9|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|20||||20|4|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20|2.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20|0|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20||||20|13.8|13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||13.8|2.8
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20||||20|0|13.8|2.8
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.52|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.15||||1.15|0.58|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.46|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.46|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.54|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.15||||1.15|0.47|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.15||||1.15|0.46|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.15||||1.15|0.58|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.52|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.52|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.15||||1.15|0.23|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.16|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15|0|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.15||||1.15|0.79|0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.16
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.15||||1.15|0|0.79|0.16
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AARP [1000]|AARP [100000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AETNA [1015]|AETNA [101529]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AMBETTER [2930]|AMBETTER [293000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|CIGNA [1260]|CIGNA PPO [126025]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|Self-pay|Self-pay|4530||||4530|906|906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|TML [1980]|TML [198000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|UNICARE [2040]|UNICARE [204000]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|WEB TPA [2115]|WEB TPA [211500]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4530||||4530||906|906
11800000|EAP|0118 - ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATI|HC PRIVATE ROOM REHAB|1|WORKER'S COMP [2125]|TML WC [212537]|4530||||4530||906|906
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|109.82||||109.82|49.42|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.82||||109.82|54.91|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109.82||||109.82|43.93|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.82||||109.82|43.93|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109.82||||109.82|51.62|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.82||||109.82|45.03|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|109.82||||109.82|43.93|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.82||||109.82|54.91|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.82||||109.82|49.42|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.82||||109.82|49.42|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|109.82||||109.82|21.96|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109.82||||109.82|15.37|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.82||||109.82|0|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|109.82||||109.82|75.78|75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109.82||||109.82||75.78|15.37
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|109.82||||109.82|0|75.78|15.37
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|42.24||||42.24|19.01|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|42.24||||42.24|21.12|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.24||||42.24|16.9|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.24||||42.24|16.9|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.24||||42.24|19.85|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|42.24||||42.24|17.32|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|42.24||||42.24|16.9|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|42.24||||42.24|21.12|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.24||||42.24|19.01|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.24||||42.24|19.01|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|42.24||||42.24|8.45|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.24||||42.24|5.91|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.24||||42.24|0|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|42.24||||42.24|29.15|29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.24||||42.24||29.15|5.91
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|42.24||||42.24|0|29.15|5.91
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|11.07||||11.07|4.98|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.07||||11.07|5.54|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.07||||11.07|4.43|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.07||||11.07|4.43|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.07||||11.07|5.2|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.07||||11.07|4.54|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.07||||11.07|4.43|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.07||||11.07|5.54|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.07||||11.07|4.98|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.07||||11.07|4.98|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|11.07||||11.07|2.21|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.07||||11.07|1.55|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.07||||11.07|0|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.07||||11.07|7.64|7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.07||||11.07||7.64|1.55
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.07||||11.07|0|7.64|1.55
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|109.82||||109.82|49.42|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.82||||109.82|54.91|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109.82||||109.82|43.93|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.82||||109.82|43.93|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109.82||||109.82|51.62|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.82||||109.82|45.03|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|109.82||||109.82|43.93|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.82||||109.82|54.91|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.82||||109.82|49.42|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.82||||109.82|49.42|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|Self-pay|Self-pay|109.82||||109.82|21.96|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109.82||||109.82|15.37|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.82||||109.82|0|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|109.82||||109.82|75.78|75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109.82||||109.82||75.78|15.37
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|109.82||||109.82|0|75.78|15.37
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AARP [1000]|AARP [100000]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AETNA [1015]|AETNA [101529]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMBETTER [2930]|AMBETTER [293000]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1099.3||||1099.3|549.65|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1099.3||||1099.3|439.72|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1099.3||||1099.3|439.72|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1099.3||||1099.3|516.67|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1099.3||||1099.3|450.71|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|1099.3||||1099.3|439.72|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1099.3||||1099.3|549.65|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|Self-pay|Self-pay|1099.3||||1099.3|219.86|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|TML [1980]|TML [198000]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1099.3||||1099.3|153.9|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNICARE [2040]|UNICARE [204000]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1099.3||||1099.3|0|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WEB TPA [2115]|WEB TPA [211500]|1099.3||||1099.3|758.52|758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1099.3||||1099.3||758.52|153.9
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|1099.3||||1099.3|0|758.52|153.9
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.85||||7.85|3.53|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.85||||7.85|3.93|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.85||||7.85|3.14|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.85||||7.85|3.14|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.85||||7.85|3.69|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.85||||7.85|3.22|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.85||||7.85|3.14|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.85||||7.85|3.93|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.85||||7.85|3.53|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.85||||7.85|3.53|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|7.85||||7.85|1.57|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.85||||7.85|1.1|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.85||||7.85|0|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.85||||7.85|5.42|5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.85||||7.85||5.42|1.1
12025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.85||||7.85|0|5.42|1.1
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AARP [1000]|AARP [100000]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AETNA [1015]|AETNA [101529]|22.69||||22.69|10.21|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AMBETTER [2930]|AMBETTER [293000]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.69||||22.69|11.35|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.69||||22.69|9.08|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.69||||22.69|9.08|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.69||||22.69|10.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.69||||22.69|9.3|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA [1260]|CIGNA PPO [126025]|22.69||||22.69|9.08|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.69||||22.69|11.35|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.69||||22.69|10.21|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.69||||22.69|10.21|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|Self-pay|Self-pay|22.69||||22.69|4.54|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|TML [1980]|TML [198000]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.69||||22.69|3.18|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UNICARE [2040]|UNICARE [204000]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.69||||22.69|0|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WEB TPA [2115]|WEB TPA [211500]|22.69||||22.69|15.66|15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.69||||22.69||15.66|3.18
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WORKER'S COMP [2125]|TML WC [212537]|22.69||||22.69|0|15.66|3.18
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|32.01||||32.01|14.4|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|32.01||||32.01|16.01|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.01||||32.01|12.8|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.01||||32.01|12.8|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.01||||32.01|15.04|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|32.01||||32.01|13.12|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|32.01||||32.01|12.8|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|32.01||||32.01|16.01|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.01||||32.01|14.4|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.01||||32.01|14.4|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|32.01||||32.01|6.4|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.01||||32.01|4.48|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.01||||32.01|0|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|32.01||||32.01|22.09|22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.01||||32.01||22.09|4.48
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|32.01||||32.01|0|22.09|4.48
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|64.04||||64.04|28.82|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.04||||64.04|32.02|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.04||||64.04|25.62|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.04||||64.04|25.62|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.04||||64.04|30.1|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.04||||64.04|26.26|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|64.04||||64.04|25.62|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.04||||64.04|32.02|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.04||||64.04|28.82|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.04||||64.04|28.82|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|64.04||||64.04|12.81|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.04||||64.04|8.97|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.04||||64.04|0|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|64.04||||64.04|44.19|44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.04||||64.04||44.19|8.97
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|64.04||||64.04|0|44.19|8.97
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|3.83||||3.83|1.72|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.83||||3.83|1.92|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.83||||3.83|1.53|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.83||||3.83|1.53|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.83||||3.83|1.8|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.83||||3.83|1.57|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|3.83||||3.83|1.53|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.83||||3.83|1.92|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.83||||3.83|1.72|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.83||||3.83|1.72|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|Self-pay|Self-pay|3.83||||3.83|0.77|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|TML [1980]|TML [198000]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.83||||3.83|0.54|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.83||||3.83|0|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|3.83||||3.83|2.64|2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.83||||3.83||2.64|0.54
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|3.83||||3.83|0|2.64|0.54
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|199.98||||199.98|89.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|199.98||||199.98|99.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|199.98||||199.98|79.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|199.98||||199.98|79.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|199.98||||199.98|93.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|199.98||||199.98|81.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|199.98||||199.98|79.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|199.98||||199.98|99.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|199.98||||199.98|89.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|199.98||||199.98|89.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|199.98||||199.98|40|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|TML [1980]|TML [198000]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|199.98||||199.98|28|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|199.98||||199.98|0|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|199.98||||199.98|137.99|137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|199.98||||199.98||137.99|28
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|199.98||||199.98|0|137.99|28
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMBETTER [2930]|AMBETTER [293000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMBETTER [2930]|AMBETTER [293000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.41||||25.41|12.71|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.41||||25.41|12.71|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.41||||25.41|11.94|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.41||||25.41|11.94|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.41||||25.41|10.42|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.41||||25.41|10.42|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|25.41||||25.41|10.16|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.41||||25.41|12.71|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.41||||25.41|12.71|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.41||||25.41|11.43|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|25.41||||25.41|5.08|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|25.41||||25.41|5.08|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|TML [1980]|TML [198000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|TML [1980]|TML [198000]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.41||||25.41|3.56|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.41||||25.41|3.56|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNICARE [2040]|UNICARE [204000]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNICARE [2040]|UNICARE [204000]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WEB TPA [2115]|WEB TPA [211500]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WEB TPA [2115]|WEB TPA [211500]|25.41||||25.41|17.53|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.41||||25.41||17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|25.41||||25.41|0|17.53|3.56
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|25.41||||25.41|0|17.53|3.56
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|78.94||||78.94|35.52|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|78.94||||78.94|39.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78.94||||78.94|31.58|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78.94||||78.94|31.58|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78.94||||78.94|37.1|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|78.94||||78.94|32.37|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|78.94||||78.94|31.58|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|78.94||||78.94|39.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.94||||78.94|35.52|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.94||||78.94|35.52|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|78.94||||78.94|15.79|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78.94||||78.94|11.05|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.94||||78.94|0|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|78.94||||78.94|54.47|54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78.94||||78.94||54.47|11.05
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|78.94||||78.94|0|54.47|11.05
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|6.42||||6.42|2.89|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.42||||6.42|3.21|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.42||||6.42|2.57|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.42||||6.42|2.57|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.42||||6.42|3.02|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.42||||6.42|2.63|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.42||||6.42|2.57|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.42||||6.42|3.21|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.42||||6.42|2.89|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.42||||6.42|2.89|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|6.42||||6.42|1.28|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.42||||6.42|0.9|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.42||||6.42|0|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.42||||6.42|4.43|4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.42||||6.42||4.43|0.9
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.42||||6.42|0|4.43|0.9
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|4.29||||4.29|1.93|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.29||||4.29|2.15|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.29||||4.29|1.72|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.29||||4.29|1.72|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.29||||4.29|2.02|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.29||||4.29|1.76|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|4.29||||4.29|1.72|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.29||||4.29|2.15|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.29||||4.29|1.93|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.29||||4.29|1.93|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|4.29||||4.29|0.86|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.29||||4.29|0.6|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.29||||4.29|0|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|4.29||||4.29|2.96|2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.29||||4.29||2.96|0.6
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|4.29||||4.29|0|2.96|0.6
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AARP [1000]|AARP [100000]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.75||||2.75|1.24|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.75||||2.75|1.38|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.75||||2.75|1.1|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.75||||2.75|1.1|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.75||||2.75|1.29|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.75||||2.75|1.13|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.75||||2.75|1.1|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.75||||2.75|1.38|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.75||||2.75|1.24|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.75||||2.75|1.24|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|Self-pay|Self-pay|2.75||||2.75|0.55|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|TML [1980]|TML [198000]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.75||||2.75|0.39|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.75||||2.75|0|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.75||||2.75|1.9|1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.75||||2.75||1.9|0.39
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.75||||2.75|0|1.9|0.39
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.62||||10.62|4.78|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.62||||10.62|5.31|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.62||||10.62|4.25|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.62||||10.62|4.25|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.62||||10.62|4.99|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.62||||10.62|4.35|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.62||||10.62|4.25|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.62||||10.62|5.31|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.62||||10.62|4.78|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.62||||10.62|4.78|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|10.62||||10.62|2.12|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.62||||10.62|1.49|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.62||||10.62|0|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.62||||10.62|7.33|7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.62||||10.62||7.33|1.49
12203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.62||||10.62|0|7.33|1.49
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.49||||4.49|2.02|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.49||||4.49|2.25|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.49||||4.49|1.8|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.49||||4.49|1.8|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.49||||4.49|2.11|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.49||||4.49|1.84|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.49||||4.49|1.8|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.49||||4.49|2.25|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.49||||4.49|2.02|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.49||||4.49|2.02|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|4.49||||4.49|0.9|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.49||||4.49|0.63|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.49||||4.49|0|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.49||||4.49|3.1|3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.49||||4.49||3.1|0.63
12204|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.49||||4.49|0|3.1|0.63
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.91||||8.91|4.01|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.91||||8.91|4.46|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.91||||8.91|3.56|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.91||||8.91|3.56|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.91||||8.91|4.19|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.91||||8.91|3.65|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.91||||8.91|3.56|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.91||||8.91|4.46|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.91||||8.91|4.01|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.91||||8.91|4.01|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|Self-pay|Self-pay|8.91||||8.91|1.78|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.91||||8.91|1.25|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.91||||8.91|0|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.91||||8.91|6.15|6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.91||||8.91||6.15|1.25
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.91||||8.91|0|6.15|1.25
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|1516.95||||1516.95|682.63|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1516.95||||1516.95|758.48|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1516.95||||1516.95|606.78|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1516.95||||1516.95|606.78|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1516.95||||1516.95|712.97|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1516.95||||1516.95|621.95|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1516.95||||1516.95|606.78|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1516.95||||1516.95|758.48|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1516.95||||1516.95|682.63|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1516.95||||1516.95|682.63|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|1516.95||||1516.95|303.39|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|TML [1980]|TML [198000]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1516.95||||1516.95|212.37|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNICARE [2040]|UNICARE [204000]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1516.95||||1516.95|0|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|1516.95||||1516.95|1046.7|1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1516.95||||1516.95||1046.7|212.37
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1516.95||||1516.95|0|1046.7|212.37
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AARP [1000]|AARP [100000]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|145.2||||145.2|65.34|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|58.08|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|58.08|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|68.24|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|59.53|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|65.34|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|65.34|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|Self-pay|Self-pay|145.2||||145.2|29.04|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|TML [1980]|TML [198000]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|20.33|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|11.88||||11.88|5.35|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.88||||11.88|5.94|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.88||||11.88|4.75|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.88||||11.88|4.75|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.88||||11.88|5.58|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.88||||11.88|4.87|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|11.88||||11.88|4.75|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.88||||11.88|5.94|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.88||||11.88|5.35|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.88||||11.88|5.35|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|Self-pay|Self-pay|11.88||||11.88|2.38|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|TML [1980]|TML [198000]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.88||||11.88|1.66|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.88||||11.88|0|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|11.88||||11.88|8.2|100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.88||||11.88||100.19|1.66
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|11.88||||11.88|0|100.19|1.66
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AARP [1000]|AARP [100000]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AETNA [1015]|AETNA [101529]|41.51||||41.51|18.68|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.51||||41.51|20.76|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.51||||41.51|16.6|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.51||||41.51|16.6|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.51||||41.51|19.51|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.51||||41.51|17.02|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|41.51||||41.51|16.6|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.51||||41.51|20.76|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.51||||41.51|18.68|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.51||||41.51|18.68|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|Self-pay|Self-pay|41.51||||41.51|8.3|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|TML [1980]|TML [198000]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.51||||41.51|5.81|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.51||||41.51|0|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|41.51||||41.51|28.64|28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.51||||41.51||28.64|5.81
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|41.51||||41.51|0|28.64|5.81
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AARP [1000]|AARP [100000]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AETNA [1015]|AETNA [101529]|200.64||||200.64|90.29|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AMBETTER [2930]|AMBETTER [293000]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|200.64||||200.64|100.32|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200.64||||200.64|80.26|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200.64||||200.64|80.26|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200.64||||200.64|94.3|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|200.64||||200.64|82.26|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|200.64||||200.64|80.26|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|200.64||||200.64|100.32|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200.64||||200.64|90.29|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200.64||||200.64|90.29|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|Self-pay|Self-pay|200.64||||200.64|40.13|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|TML [1980]|TML [198000]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200.64||||200.64|28.09|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UNICARE [2040]|UNICARE [204000]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200.64||||200.64|0|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WEB TPA [2115]|WEB TPA [211500]|200.64||||200.64|138.44|138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200.64||||200.64||138.44|28.09
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|200.64||||200.64|0|138.44|28.09
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|79.6||||79.6|35.82|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.6||||79.6|39.8|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.6||||79.6|31.84|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.6||||79.6|31.84|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.6||||79.6|37.41|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.6||||79.6|32.64|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|79.6||||79.6|31.84|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.6||||79.6|39.8|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.6||||79.6|35.82|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.6||||79.6|35.82|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|79.6||||79.6|15.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.6||||79.6|11.14|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.6||||79.6|0|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|79.6||||79.6|54.92|54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.6||||79.6||54.92|11.14
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|79.6||||79.6|0|54.92|11.14
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AARP [1000]|AARP [100000]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AETNA [1015]|AETNA [101529]|77.17||||77.17|34.73|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMBETTER [2930]|AMBETTER [293000]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|77.17||||77.17|38.59|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77.17||||77.17|30.87|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77.17||||77.17|30.87|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77.17||||77.17|36.27|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|77.17||||77.17|31.64|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA PPO [126025]|77.17||||77.17|30.87|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|77.17||||77.17|38.59|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.17||||77.17|34.73|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.17||||77.17|34.73|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|Self-pay|Self-pay|77.17||||77.17|15.43|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|TML [1980]|TML [198000]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77.17||||77.17|10.8|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNICARE [2040]|UNICARE [204000]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77.17||||77.17|0|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WEB TPA [2115]|WEB TPA [211500]|77.17||||77.17|53.25|53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77.17||||77.17||53.25|10.8
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WORKER'S COMP [2125]|TML WC [212537]|77.17||||77.17|0|53.25|10.8
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|60.14||||60.14|27.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|60.14||||60.14|30.07|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60.14||||60.14|24.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60.14||||60.14|24.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60.14||||60.14|28.27|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|60.14||||60.14|24.66|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|60.14||||60.14|24.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|60.14||||60.14|30.07|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60.14||||60.14|27.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60.14||||60.14|27.06|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|60.14||||60.14|12.03|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60.14||||60.14|8.42|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60.14||||60.14|0|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|60.14||||60.14|41.5|41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60.14||||60.14||41.5|8.42
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|60.14||||60.14|0|41.5|8.42
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|191.8||||191.8|86.31|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|191.8||||191.8|95.9|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191.8||||191.8|76.72|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191.8||||191.8|76.72|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191.8||||191.8|90.15|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|191.8||||191.8|78.64|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|191.8||||191.8|76.72|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|191.8||||191.8|95.9|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191.8||||191.8|86.31|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191.8||||191.8|86.31|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|191.8||||191.8|38.36|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191.8||||191.8|26.85|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191.8||||191.8|0|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|191.8||||191.8|132.34|132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191.8||||191.8||132.34|26.85
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|191.8||||191.8|0|132.34|26.85
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AARP [1000]|AARP [100000]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|71.28|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|63.36|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|63.36|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|74.45|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|64.94|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|71.28|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|71.28|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|Self-pay|Self-pay|158.4||||158.4|31.68|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|22.18|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|0|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4||109.3|22.18
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|0|109.3|22.18
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|26.27||||26.27|11.82|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.27||||26.27|13.14|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.27||||26.27|10.51|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.27||||26.27|10.51|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.27||||26.27|12.35|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.27||||26.27|10.77|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|26.27||||26.27|10.51|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.27||||26.27|13.14|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.27||||26.27|11.82|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.27||||26.27|11.82|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|26.27||||26.27|5.25|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.27||||26.27|3.68|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.27||||26.27|0|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|26.27||||26.27|18.13|18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.27||||26.27||18.13|3.68
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|26.27||||26.27|0|18.13|3.68
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AARP [1000]|AARP [100000]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AETNA [1015]|AETNA [101529]|27.08||||27.08|12.19|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.08||||27.08|13.54|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.08||||27.08|10.83|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.08||||27.08|10.83|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.08||||27.08|12.73|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.08||||27.08|11.1|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|27.08||||27.08|10.83|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.08||||27.08|13.54|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.08||||27.08|12.19|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.08||||27.08|12.19|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|Self-pay|Self-pay|27.08||||27.08|5.42|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|TML [1980]|TML [198000]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.08||||27.08|3.79|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.08||||27.08|0|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|27.08||||27.08|18.69|18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.08||||27.08||18.69|3.79
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|27.08||||27.08|0|18.69|3.79
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AARP [1000]|AARP [100000]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AETNA [1015]|AETNA [101529]|63.09||||63.09|28.39|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMBETTER [2930]|AMBETTER [293000]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|63.09||||63.09|31.55|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.09||||63.09|25.24|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.09||||63.09|25.24|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.09||||63.09|29.65|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|63.09||||63.09|25.87|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA [1260]|CIGNA PPO [126025]|63.09||||63.09|25.24|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|63.09||||63.09|31.55|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.09||||63.09|28.39|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.09||||63.09|28.39|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|Self-pay|Self-pay|63.09||||63.09|12.62|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|TML [1980]|TML [198000]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.09||||63.09|8.83|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNICARE [2040]|UNICARE [204000]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.09||||63.09|0|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WEB TPA [2115]|WEB TPA [211500]|63.09||||63.09|43.53|43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.09||||63.09||43.53|8.83
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WORKER'S COMP [2125]|TML WC [212537]|63.09||||63.09|0|43.53|8.83
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AARP [1000]|AARP [100000]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AETNA [1015]|AETNA [101529]|51.93||||51.93|23.37|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMBETTER [2930]|AMBETTER [293000]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.93||||51.93|25.97|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.93||||51.93|20.77|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.93||||51.93|20.77|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.93||||51.93|24.41|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.93||||51.93|21.29|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA [1260]|CIGNA PPO [126025]|51.93||||51.93|20.77|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.93||||51.93|25.97|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.93||||51.93|23.37|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.93||||51.93|23.37|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|Self-pay|Self-pay|51.93||||51.93|10.39|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|TML [1980]|TML [198000]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.93||||51.93|7.27|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UNICARE [2040]|UNICARE [204000]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.93||||51.93|0|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WEB TPA [2115]|WEB TPA [211500]|51.93||||51.93|35.83|35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.93||||51.93||35.83|7.27
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WORKER'S COMP [2125]|TML WC [212537]|51.93||||51.93|0|35.83|7.27
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|204.6||||204.6|92.07|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|204.6||||204.6|102.3|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204.6||||204.6|81.84|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204.6||||204.6|81.84|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204.6||||204.6|96.16|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|204.6||||204.6|83.89|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|204.6||||204.6|81.84|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|204.6||||204.6|102.3|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204.6||||204.6|92.07|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204.6||||204.6|92.07|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|204.6||||204.6|40.92|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204.6||||204.6|28.64|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204.6||||204.6|0|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|204.6||||204.6|141.17|141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204.6||||204.6||141.17|28.64
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|204.6||||204.6|0|141.17|28.64
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|3298.16||||3298.16|1484.17|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3298.16||||3298.16|1649.08|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3298.16||||3298.16|1319.26|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3298.16||||3298.16|1319.26|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3298.16||||3298.16|1550.14|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3298.16||||3298.16|1352.25|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|3298.16||||3298.16|1319.26|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3298.16||||3298.16|1649.08|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3298.16||||3298.16|1484.17|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3298.16||||3298.16|1484.17|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|Self-pay|Self-pay|3298.16||||3298.16|659.63|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|TML [1980]|TML [198000]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3298.16||||3298.16|461.74|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3298.16||||3298.16|0|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|3298.16||||3298.16|2275.73|2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3298.16||||3298.16||2275.73|461.74
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|3298.16||||3298.16|0|2275.73|461.74
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|5278.56||||5278.56|2375.35|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5278.56||||5278.56|2639.28|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5278.56||||5278.56|2111.42|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5278.56||||5278.56|2111.42|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5278.56||||5278.56|2480.92|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5278.56||||5278.56|2164.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|5278.56||||5278.56|2639.28|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5278.56||||5278.56|2639.28|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5278.56||||5278.56|2375.35|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5278.56||||5278.56|2375.35|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|5278.56||||5278.56|1055.71|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5278.56||||5278.56|739|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5278.56||||5278.56|0|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|5278.56||||5278.56|3642.21|3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5278.56||||5278.56||3642.21|739
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|5278.56||||5278.56|0|3642.21|739
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AARP [1000]|AARP [100000]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AETNA [1015]|AETNA [101529]|139.2||||139.2|62.64|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AMBETTER [2930]|AMBETTER [293000]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139.2||||139.2|69.6|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.2||||139.2|55.68|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.2||||139.2|55.68|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.2||||139.2|65.42|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139.2||||139.2|57.07|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA [1260]|CIGNA PPO [126025]|139.2||||139.2|55.68|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139.2||||139.2|69.6|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.2||||139.2|62.64|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.2||||139.2|62.64|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|Self-pay|Self-pay|139.2||||139.2|27.84|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|TML [1980]|TML [198000]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.2||||139.2|19.49|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UNICARE [2040]|UNICARE [204000]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.2||||139.2|0|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WEB TPA [2115]|WEB TPA [211500]|139.2||||139.2|96.05|96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.2||||139.2||96.05|19.49
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WORKER'S COMP [2125]|TML WC [212537]|139.2||||139.2|0|96.05|19.49
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|11.88||||11.88|5.35|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.88||||11.88|5.94|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.88||||11.88|4.75|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.88||||11.88|4.75|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.88||||11.88|5.58|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.88||||11.88|4.87|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|11.88||||11.88|4.75|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.88||||11.88|5.94|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.88||||11.88|5.35|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.88||||11.88|5.35|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|11.88||||11.88|2.38|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.88||||11.88|1.66|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.88||||11.88|0|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|11.88||||11.88|8.2|8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.88||||11.88||8.2|1.66
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|11.88||||11.88|0|8.2|1.66
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AARP [1000]|AARP [100000]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|115.5||||115.5|51.98|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|115.5||||115.5|57.75|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|115.5||||115.5|46.2|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115.5||||115.5|46.2|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|115.5||||115.5|54.29|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|115.5||||115.5|47.36|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|115.5||||115.5|46.2|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|115.5||||115.5|57.75|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115.5||||115.5|51.98|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115.5||||115.5|51.98|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|Self-pay|Self-pay|115.5||||115.5|23.1|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|TML [1980]|TML [198000]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|115.5||||115.5|16.17|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115.5||||115.5|0|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|115.5||||115.5|79.7|79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|115.5||||115.5||79.7|16.17
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|115.5||||115.5|0|79.7|16.17
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|234.45||||234.45|105.5|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|234.45||||234.45|117.23|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234.45||||234.45|93.78|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234.45||||234.45|93.78|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234.45||||234.45|110.19|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|234.45||||234.45|96.12|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|234.45||||234.45|93.78|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|234.45||||234.45|117.23|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234.45||||234.45|105.5|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234.45||||234.45|105.5|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|234.45||||234.45|46.89|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234.45||||234.45|32.82|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234.45||||234.45|0|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|234.45||||234.45|161.77|161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234.45||||234.45||161.77|32.82
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|234.45||||234.45|105.5|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|234.45||||234.45|117.23|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234.45||||234.45|93.78|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234.45||||234.45|93.78|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234.45||||234.45|110.19|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|234.45||||234.45|96.12|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|234.45||||234.45|93.78|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|234.45||||234.45|117.23|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234.45||||234.45|105.5|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234.45||||234.45|105.5|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|234.45||||234.45|46.89|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234.45||||234.45|32.82|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234.45||||234.45|0|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|234.45||||234.45|161.77|161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234.45||||234.45||161.77|32.82
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|234.45||||234.45|0|161.77|32.82
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|2829.57||||2829.57|1273.31|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2829.57||||2829.57|1414.79|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2829.57||||2829.57|1131.83|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2829.57||||2829.57|1131.83|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2829.57||||2829.57|1329.9|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2829.57||||2829.57|1160.12|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|2829.57||||2829.57|1131.83|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2829.57||||2829.57|1414.79|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2829.57||||2829.57|1273.31|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2829.57||||2829.57|1273.31|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|Self-pay|Self-pay|2829.57||||2829.57|565.91|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2829.57||||2829.57|396.14|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2829.57||||2829.57|0|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|2829.57||||2829.57|1952.4|1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2829.57||||2829.57||1952.4|396.14
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|2829.57||||2829.57|0|1952.4|396.14
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AARP [1000]|AARP [100000]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA [1015]|AETNA [101529]|69.96||||69.96|31.48|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMBETTER [2930]|AMBETTER [293000]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69.96||||69.96|34.98|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.96||||69.96|27.98|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.96||||69.96|27.98|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.96||||69.96|32.88|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69.96||||69.96|28.68|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA PPO [126025]|69.96||||69.96|27.98|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69.96||||69.96|34.98|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.96||||69.96|31.48|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.96||||69.96|31.48|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|Self-pay|Self-pay|69.96||||69.96|13.99|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|TML [1980]|TML [198000]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.96||||69.96|9.79|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNICARE [2040]|UNICARE [204000]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.96||||69.96|0|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WEB TPA [2115]|WEB TPA [211500]|69.96||||69.96|48.27|48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.96||||69.96||48.27|9.79
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WORKER'S COMP [2125]|TML WC [212537]|69.96||||69.96|0|48.27|9.79
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|2.88||||2.88|1.3|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.88||||2.88|1.44|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.88||||2.88|1.15|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.88||||2.88|1.15|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.88||||2.88|1.35|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.88||||2.88|1.18|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|2.88||||2.88|1.15|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.88||||2.88|1.44|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.88||||2.88|1.3|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.88||||2.88|1.3|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|2.88||||2.88|0.58|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|TML [1980]|TML [198000]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.88||||2.88|0.4|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNICARE [2040]|UNICARE [204000]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.88||||2.88|0|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|2.88||||2.88|1.99|1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.88||||2.88||1.99|0.4
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|2.88||||2.88|0|1.99|0.4
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AARP [1000]|AARP [100000]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AETNA [1015]|AETNA [101529]|24.95||||24.95|11.23|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AMBETTER [2930]|AMBETTER [293000]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.95||||24.95|12.48|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.95||||24.95|9.98|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.95||||24.95|9.98|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.95||||24.95|11.73|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.95||||24.95|10.23|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|CIGNA [1260]|CIGNA PPO [126025]|24.95||||24.95|9.98|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.95||||24.95|12.48|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.95||||24.95|11.23|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.95||||24.95|11.23|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|Self-pay|Self-pay|24.95||||24.95|4.99|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|TML [1980]|TML [198000]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.95||||24.95|3.49|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|UNICARE [2040]|UNICARE [204000]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.95||||24.95|0|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|WEB TPA [2115]|WEB TPA [211500]|24.95||||24.95|17.22|17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.95||||24.95||17.22|3.49
125980|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE|1.8 mL|WORKER'S COMP [2125]|TML WC [212537]|24.95||||24.95|0|17.22|3.49
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AARP [1000]|AARP [100000]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.69||||0.69|0.31|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.69||||0.69|0.35|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.69||||0.69|0.28|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.69||||0.69|0.28|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.69||||0.69|0.32|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.69||||0.69|0.28|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.69||||0.69|0.28|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.69||||0.69|0.35|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.69||||0.69|0.31|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.69||||0.69|0.31|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|Self-pay|Self-pay|0.69||||0.69|0.14|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|TML [1980]|TML [198000]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.69||||0.69|0.1|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.69||||0.69|0|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.69||||0.69|0.48|0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.69||||0.69||0.48|0.1
126173|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.69||||0.69|0|0.48|0.1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|10.35||||10.35|4.66|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.35||||10.35|5.18|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.35||||10.35|4.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.35||||10.35|4.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.35||||10.35|4.86|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.35||||10.35|4.24|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.35||||10.35|4.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.35||||10.35|5.18|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.35||||10.35|4.66|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.35||||10.35|4.66|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|10.35||||10.35|2.07|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.35||||10.35|1.45|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.35||||10.35|0|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.35||||10.35|7.14|7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.35||||10.35||7.14|1.45
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.35||||10.35|0|7.14|1.45
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AARP [1000]|AARP [100000]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AETNA [1015]|AETNA [101529]|277.2||||277.2|124.74|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|138.6|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|110.88|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|110.88|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|130.28|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|113.65|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|138.6|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|124.74|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|124.74|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|Self-pay|Self-pay|277.2||||277.2|55.44|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|TML [1980]|TML [198000]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|38.81|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNICARE [2040]|UNICARE [204000]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.2||||277.2||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AARP [1000]|AARP [100000]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AETNA [1015]|AETNA [101529]|1042.8||||1042.8|469.26|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMBETTER [2930]|AMBETTER [293000]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1042.8||||1042.8|521.4|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1042.8||||1042.8|417.12|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1042.8||||1042.8|417.12|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1042.8||||1042.8|490.12|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1042.8||||1042.8|427.55|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1042.8||||1042.8|417.12|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1042.8||||1042.8|521.4|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1042.8||||1042.8|469.26|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1042.8||||1042.8|469.26|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|Self-pay|Self-pay|1042.8||||1042.8|208.56|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|TML [1980]|TML [198000]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1042.8||||1042.8|145.99|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UNICARE [2040]|UNICARE [204000]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1042.8||||1042.8|0|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WEB TPA [2115]|WEB TPA [211500]|1042.8||||1042.8|719.53|719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1042.8||||1042.8||719.53|38.81
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1042.8||||1042.8|0|719.53|38.81
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.92||||1.92|0.86|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.92||||1.92|0.96|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.92||||1.92|0.77|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.92||||1.92|0.77|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.92||||1.92|0.9|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.92||||1.92|0.79|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.92||||1.92|0.77|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.92||||1.92|0.96|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.92||||1.92|0.86|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.92||||1.92|0.86|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|Self-pay|Self-pay|1.92||||1.92|0.38|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|TML [1980]|TML [198000]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.92||||1.92|0.27|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.92||||1.92|0|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.92||||1.92|1.32|1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.92||||1.92||1.32|0.27
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.92||||1.92|0|1.32|0.27
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|12.82||||12.82|5.77|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.82||||12.82|6.41|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.82||||12.82|5.13|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.82||||12.82|5.13|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.82||||12.82|6.03|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.82||||12.82|5.26|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.82||||12.82|5.13|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.82||||12.82|6.41|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.82||||12.82|5.77|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.82||||12.82|5.77|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|12.82||||12.82|2.56|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.82||||12.82|1.79|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.82||||12.82|0|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.82||||12.82|8.85|8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.82||||12.82||8.85|1.79
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.82||||12.82|0|8.85|1.79
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|181.44||||181.44|81.65|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.44||||181.44|90.72|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.44||||181.44|72.58|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.44||||181.44|72.58|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.44||||181.44|85.28|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.44||||181.44|74.39|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|181.44||||181.44|72.58|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.44||||181.44|90.72|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.44||||181.44|81.65|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.44||||181.44|81.65|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|181.44||||181.44|36.29|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.44||||181.44|25.4|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.44||||181.44|0|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|181.44||||181.44|125.19|125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.44||||181.44||125.19|25.4
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|181.44||||181.44|0|125.19|25.4
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|241.37||||241.37|108.62|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|241.37||||241.37|120.69|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|241.37||||241.37|96.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|241.37||||241.37|96.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|241.37||||241.37|113.44|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|241.37||||241.37|98.96|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|241.37||||241.37|96.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|241.37||||241.37|120.69|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|241.37||||241.37|108.62|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|241.37||||241.37|108.62|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|241.37||||241.37|48.27|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|241.37||||241.37|33.79|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|241.37||||241.37|0|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|241.37||||241.37|166.55|166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|241.37||||241.37||166.55|33.79
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|241.37||||241.37|108.62|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|241.37||||241.37|120.69|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|241.37||||241.37|96.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|241.37||||241.37|96.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|241.37||||241.37|113.44|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|241.37||||241.37|98.96|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|241.37||||241.37|96.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|241.37||||241.37|120.69|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|241.37||||241.37|108.62|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|241.37||||241.37|108.62|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|Self-pay|Self-pay|241.37||||241.37|48.27|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|241.37||||241.37|33.79|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|241.37||||241.37|0|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|241.37||||241.37|166.55|166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|241.37||||241.37||166.55|33.79
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|241.37||||241.37|0|166.55|33.79
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|193.25||||193.25|86.96|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.25||||193.25|96.63|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193.25||||193.25|77.3|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193.25||||193.25|77.3|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193.25||||193.25|90.83|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.25||||193.25|79.23|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|193.25||||193.25|77.3|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.25||||193.25|96.63|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.25||||193.25|86.96|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.25||||193.25|86.96|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|193.25||||193.25|38.65|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193.25||||193.25|27.06|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.25||||193.25|0|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|193.25||||193.25|133.34|133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193.25||||193.25||133.34|27.06
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|193.25||||193.25|0|133.34|27.06
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|217.8||||217.8|98.01|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|217.8||||217.8|108.9|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.8||||217.8|87.12|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.8||||217.8|87.12|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.8||||217.8|102.37|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|217.8||||217.8|89.3|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|217.8||||217.8|87.12|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|217.8||||217.8|108.9|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.8||||217.8|98.01|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.8||||217.8|98.01|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|217.8||||217.8|43.56|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.8||||217.8|30.49|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.8||||217.8|0|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|217.8||||217.8|150.28|150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.8||||217.8||150.28|30.49
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|217.8||||217.8|0|150.28|30.49
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AARP [1000]|AARP [100000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AETNA [1015]|AETNA [101529]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AMBETTER [2930]|AMBETTER [293000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|CIGNA [1260]|CIGNA PPO [126025]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|Self-pay|Self-pay|4117||||4117|823.4|823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|TML [1980]|TML [198000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|UNICARE [2040]|UNICARE [204000]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|WEB TPA [2115]|WEB TPA [211500]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4117||||4117||823.4|823.4
12800000|EAP|0128 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABIL|HC SEMI-PRIVATE ROOM REHAB|1|WORKER'S COMP [2125]|TML WC [212537]|4117||||4117||823.4|823.4
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.39||||5.39|2.43|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.39||||5.39|2.7|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.39||||5.39|2.16|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.39||||5.39|2.16|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.39||||5.39|2.53|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.39||||5.39|2.21|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.39||||5.39|2.16|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.39||||5.39|2.7|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.39||||5.39|2.43|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.39||||5.39|2.43|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|5.39||||5.39|1.08|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.39||||5.39|0.75|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.39||||5.39|0|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.39||||5.39|3.72|3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.39||||5.39||3.72|0.75
12803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.39||||5.39|0|3.72|0.75
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AARP [1000]|AARP [100000]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AETNA [1015]|AETNA [101529]|4736.3||||4736.3|2131.34|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMBETTER [2930]|AMBETTER [293000]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4736.3||||4736.3|2368.15|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4736.3||||4736.3|1894.52|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4736.3||||4736.3|1894.52|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4736.3||||4736.3|2226.06|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4736.3||||4736.3|1941.88|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA [1260]|CIGNA PPO [126025]|4736.3||||4736.3|1894.52|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4736.3||||4736.3|2368.15|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4736.3||||4736.3|2131.34|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4736.3||||4736.3|2131.34|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|Self-pay|Self-pay|4736.3||||4736.3|947.26|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|TML [1980]|TML [198000]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4736.3||||4736.3|663.08|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNICARE [2040]|UNICARE [204000]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4736.3||||4736.3|0|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WEB TPA [2115]|WEB TPA [211500]|4736.3||||4736.3|3268.05|3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4736.3||||4736.3||3268.05|663.08
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WORKER'S COMP [2125]|TML WC [212537]|4736.3||||4736.3|0|3268.05|663.08
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|237.87||||237.87|107.04|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.87||||237.87|118.94|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.87||||237.87|95.15|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.87||||237.87|95.15|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.87||||237.87|111.8|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.87||||237.87|97.53|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|237.87||||237.87|95.15|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.87||||237.87|118.94|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.87||||237.87|107.04|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.87||||237.87|107.04|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|237.87||||237.87|47.57|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|TML [1980]|TML [198000]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.87||||237.87|33.3|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.87||||237.87|0|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|237.87||||237.87|164.13|164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237.87||||237.87||164.13|33.3
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|237.87||||237.87|0|164.13|33.3
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AARP [1000]|AARP [100000]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AETNA [1015]|AETNA [101529]|84.48||||84.48|38.02|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMBETTER [2930]|AMBETTER [293000]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84.48||||84.48|42.24|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.48||||84.48|33.79|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.48||||84.48|33.79|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.48||||84.48|39.71|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84.48||||84.48|34.64|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|84.48||||84.48|33.79|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84.48||||84.48|42.24|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.48||||84.48|38.02|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.48||||84.48|38.02|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|Self-pay|Self-pay|84.48||||84.48|16.9|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|TML [1980]|TML [198000]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.48||||84.48|11.83|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNICARE [2040]|UNICARE [204000]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.48||||84.48|0|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WEB TPA [2115]|WEB TPA [211500]|84.48||||84.48|58.29|58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.48||||84.48||58.29|11.83
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|84.48||||84.48|0|58.29|11.83
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|108.14||||108.14|48.66|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108.14||||108.14|54.07|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.14||||108.14|43.26|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.14||||108.14|43.26|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.14||||108.14|50.83|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108.14||||108.14|44.34|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|108.14||||108.14|43.26|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108.14||||108.14|54.07|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.14||||108.14|48.66|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.14||||108.14|48.66|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|108.14||||108.14|21.63|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.14||||108.14|15.14|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.14||||108.14|0|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|108.14||||108.14|74.62|74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.14||||108.14||74.62|15.14
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|108.14||||108.14|0|74.62|15.14
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AARP [1000]|AARP [100000]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AETNA [1015]|AETNA [101529]|122.24||||122.24|55.01|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AMBETTER [2930]|AMBETTER [293000]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122.24||||122.24|61.12|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122.24||||122.24|48.9|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122.24||||122.24|48.9|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122.24||||122.24|57.45|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122.24||||122.24|50.12|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|CIGNA [1260]|CIGNA PPO [126025]|122.24||||122.24|48.9|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122.24||||122.24|61.12|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122.24||||122.24|55.01|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122.24||||122.24|55.01|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|Self-pay|Self-pay|122.24||||122.24|24.45|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|TML [1980]|TML [198000]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122.24||||122.24|17.11|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|UNICARE [2040]|UNICARE [204000]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|WEB TPA [2115]|WEB TPA [211500]|122.24||||122.24|84.35|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122.24||||122.24||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|20 mL|WORKER'S COMP [2125]|TML WC [212537]|122.24||||122.24|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AARP [1000]|AARP [100000]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AETNA [1015]|AETNA [101529]|75.9||||75.9|34.16|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AMBETTER [2930]|AMBETTER [293000]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.9||||75.9|37.95|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.9||||75.9|30.36|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.9||||75.9|30.36|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.9||||75.9|35.67|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.9||||75.9|31.12|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA [1260]|CIGNA PPO [126025]|75.9||||75.9|30.36|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.9||||75.9|37.95|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.9||||75.9|34.16|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.9||||75.9|34.16|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|Self-pay|Self-pay|75.9||||75.9|15.18|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|TML [1980]|TML [198000]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.9||||75.9|10.63|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UNICARE [2040]|UNICARE [204000]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.9||||75.9|0|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WEB TPA [2115]|WEB TPA [211500]|75.9||||75.9|52.37|84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.9||||75.9||84.35|10.63
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WORKER'S COMP [2125]|TML WC [212537]|75.9||||75.9|0|84.35|10.63
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AARP [1000]|AARP [100000]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AETNA [1015]|AETNA [101529]|237.6||||237.6|106.92|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMBETTER [2930]|AMBETTER [293000]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.6||||237.6|118.8|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.6||||237.6|95.04|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.6||||237.6|95.04|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.6||||237.6|111.67|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.6||||237.6|97.42|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA [1260]|CIGNA PPO [126025]|237.6||||237.6|95.04|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.6||||237.6|118.8|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.6||||237.6|106.92|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.6||||237.6|106.92|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|Self-pay|Self-pay|237.6||||237.6|47.52|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|TML [1980]|TML [198000]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.6||||237.6|9.8|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UNICARE [2040]|UNICARE [204000]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.6||||237.6|0|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WEB TPA [2115]|WEB TPA [211500]|237.6||||237.6|163.94|163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237.6||||237.6||163.94|9.8
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WORKER'S COMP [2125]|TML WC [212537]|237.6||||237.6|0|163.94|9.8
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|76.56||||76.56|34.45|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|76.56||||76.56|38.28|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.56||||76.56|30.62|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.56||||76.56|30.62|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.56||||76.56|35.98|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|76.56||||76.56|31.39|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|76.56||||76.56|30.62|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|76.56||||76.56|38.28|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.56||||76.56|34.45|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.56||||76.56|34.45|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|76.56||||76.56|15.31|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.56||||76.56|10.72|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.56||||76.56|0|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|76.56||||76.56|52.83|52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.56||||76.56||52.83|10.72
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|76.56||||76.56|0|52.83|10.72
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.99||||10.99|4.95|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.99||||10.99|5.5|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.99||||10.99|4.4|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.99||||10.99|4.4|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.99||||10.99|5.17|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.99||||10.99|4.51|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.99||||10.99|4.4|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.99||||10.99|5.5|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.99||||10.99|4.95|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.99||||10.99|4.95|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|Self-pay|Self-pay|10.99||||10.99|2.2|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.99||||10.99|1.54|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.99||||10.99|0|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.99||||10.99|7.58|7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.99||||10.99||7.58|1.54
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.99||||10.99|0|7.58|1.54
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AARP [1000]|AARP [100000]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.24||||4.24|1.91|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.24||||4.24|2.12|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.24||||4.24|1.7|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.24||||4.24|1.7|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.24||||4.24|1.99|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.24||||4.24|1.74|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.24||||4.24|1.7|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.24||||4.24|2.12|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.24||||4.24|1.91|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.24||||4.24|1.91|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|Self-pay|Self-pay|4.24||||4.24|0.85|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|TML [1980]|TML [198000]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.24||||4.24|0.59|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.24||||4.24|0|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.24||||4.24|2.93|2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.24||||4.24||2.93|0.59
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.24||||4.24|0|2.93|0.59
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AARP [1000]|AARP [100000]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AETNA [1015]|AETNA [101529]|26.8||||26.8|12.06|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMBETTER [2930]|AMBETTER [293000]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.8||||26.8|13.4|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.8||||26.8|10.72|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.8||||26.8|10.72|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.8||||26.8|12.6|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.8||||26.8|10.99|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA [1260]|CIGNA PPO [126025]|26.8||||26.8|10.72|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.8||||26.8|13.4|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.8||||26.8|12.06|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.8||||26.8|12.06|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|Self-pay|Self-pay|26.8||||26.8|5.36|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|TML [1980]|TML [198000]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.8||||26.8|3.75|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNICARE [2040]|UNICARE [204000]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.8||||26.8|0|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WEB TPA [2115]|WEB TPA [211500]|26.8||||26.8|18.49|18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.8||||26.8||18.49|3.75
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WORKER'S COMP [2125]|TML WC [212537]|26.8||||26.8|0|18.49|3.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|12.37||||12.37|5.57|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.37||||12.37|6.19|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.37||||12.37|4.95|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.37||||12.37|4.95|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.37||||12.37|5.81|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.37||||12.37|5.07|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.37||||12.37|4.95|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.37||||12.37|6.19|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.37||||12.37|5.57|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.37||||12.37|5.57|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|12.37||||12.37|2.47|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TML [1980]|TML [198000]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.37||||12.37|1.73|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.37||||12.37|0|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.37||||12.37|8.54|8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.37||||12.37||8.54|1.73
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.37||||12.37|0|8.54|1.73
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AARP [1000]|AARP [100000]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AETNA [1015]|AETNA [101529]|193.38||||193.38|87.02|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.38||||193.38|96.69|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193.38||||193.38|77.35|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193.38||||193.38|77.35|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193.38||||193.38|90.89|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.38||||193.38|79.29|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|193.38||||193.38|77.35|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.38||||193.38|96.69|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.38||||193.38|87.02|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.38||||193.38|87.02|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|Self-pay|Self-pay|193.38||||193.38|38.68|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|TML [1980]|TML [198000]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193.38||||193.38|27.07|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNICARE [2040]|UNICARE [204000]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.38||||193.38|0|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|193.38||||193.38|133.43|133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193.38||||193.38||133.43|27.07
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|193.38||||193.38|0|133.43|27.07
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|105.6||||105.6|47.52|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.6||||105.6|52.8|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.6||||105.6|42.24|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.6||||105.6|42.24|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.6||||105.6|49.63|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|105.6||||105.6|43.3|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|105.6||||105.6|42.24|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.6||||105.6|52.8|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.6||||105.6|47.52|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.6||||105.6|47.52|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|105.6||||105.6|21.12|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.6||||105.6|14.78|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.6||||105.6|0|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|105.6||||105.6|72.86|72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.6||||105.6||72.86|14.78
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|105.6||||105.6|0|72.86|14.78
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|381.34||||381.34|171.6|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|381.34||||381.34|190.67|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.34||||381.34|152.54|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.34||||381.34|152.54|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.34||||381.34|179.23|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|381.34||||381.34|156.35|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|381.34||||381.34|152.54|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|381.34||||381.34|190.67|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.34||||381.34|171.6|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.34||||381.34|171.6|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|381.34||||381.34|76.27|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.34||||381.34|53.39|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|381.34||||381.34|263.12|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.34||||381.34||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|381.34||||381.34|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|762.67||||762.67|343.2|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|762.67||||762.67|381.34|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|762.67||||762.67|305.07|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|762.67||||762.67|305.07|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|762.67||||762.67|358.45|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|762.67||||762.67|312.69|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|762.67||||762.67|305.07|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|762.67||||762.67|381.34|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|762.67||||762.67|343.2|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|762.67||||762.67|343.2|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|762.67||||762.67|152.53|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|762.67||||762.67|106.77|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|762.67||||762.67|0|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|762.67||||762.67|526.24|526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|762.67||||762.67||526.24|53.39
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|762.67||||762.67|0|526.24|53.39
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|203.55||||203.55|91.6|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203.55||||203.55|101.78|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203.55||||203.55|81.42|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203.55||||203.55|81.42|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203.55||||203.55|95.67|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203.55||||203.55|83.46|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|203.55||||203.55|81.42|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203.55||||203.55|101.78|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203.55||||203.55|91.6|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203.55||||203.55|91.6|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|203.55||||203.55|40.71|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|TML [1980]|TML [198000]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203.55||||203.55|28.5|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNICARE [2040]|UNICARE [204000]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203.55||||203.55|0|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|203.55||||203.55|140.45|140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203.55||||203.55||140.45|28.5
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|203.55||||203.55|0|140.45|28.5
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|128.24||||128.24|57.71|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.24||||128.24|64.12|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.24||||128.24|51.3|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.24||||128.24|51.3|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.24||||128.24|60.27|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.24||||128.24|52.58|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|128.24||||128.24|51.3|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.24||||128.24|64.12|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.24||||128.24|57.71|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.24||||128.24|57.71|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|Self-pay|Self-pay|128.24||||128.24|25.65|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|TML [1980]|TML [198000]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.24||||128.24|17.95|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.24||||128.24|0|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|128.24||||128.24|88.49|88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.24||||128.24||88.49|17.95
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|128.24||||128.24|57.71|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.24||||128.24|64.12|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.24||||128.24|51.3|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.24||||128.24|51.3|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.24||||128.24|60.27|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.24||||128.24|52.58|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|128.24||||128.24|51.3|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.24||||128.24|64.12|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.24||||128.24|57.71|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.24||||128.24|57.71|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|Self-pay|Self-pay|128.24||||128.24|25.65|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|TML [1980]|TML [198000]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.24||||128.24|17.95|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.24||||128.24|0|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|128.24||||128.24|88.49|88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.24||||128.24||88.49|17.95
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|128.24||||128.24|0|88.49|17.95
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.44||||0.44|0.2|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.44||||0.44|0.22|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.44||||0.44|0.18|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.44||||0.44|0.18|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.44||||0.44|0.21|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.44||||0.44|0.18|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.44||||0.44|0.18|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.44||||0.44|0.22|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.44||||0.44|0.2|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.44||||0.44|0.2|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|Self-pay|Self-pay|0.44||||0.44|0.09|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|TML [1980]|TML [198000]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.44||||0.44|0.06|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.44||||0.44|0|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.44||||0.44|0.3|0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.44||||0.44||0.3|0.06
1300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.44||||0.44|0|0.3|0.06
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|90.85||||90.85|40.88|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.85||||90.85|45.43|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.85||||90.85|36.34|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.85||||90.85|36.34|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.85||||90.85|42.7|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.85||||90.85|37.25|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.85||||90.85|36.34|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.85||||90.85|45.43|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.85||||90.85|40.88|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.85||||90.85|40.88|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|Self-pay|Self-pay|90.85||||90.85|18.17|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|TML [1980]|TML [198000]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.85||||90.85|12.72|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.85||||90.85|0|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.85||||90.85|62.69|62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.85||||90.85||62.69|12.72
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.85||||90.85|0|62.69|12.72
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AARP [1000]|AARP [100000]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|93.99||||93.99|42.3|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93.99||||93.99|47|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93.99||||93.99|37.6|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93.99||||93.99|37.6|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93.99||||93.99|44.18|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93.99||||93.99|38.54|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|93.99||||93.99|37.6|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93.99||||93.99|47|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93.99||||93.99|42.3|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93.99||||93.99|42.3|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|Self-pay|Self-pay|93.99||||93.99|18.8|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|TML [1980]|TML [198000]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93.99||||93.99|13.16|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93.99||||93.99|0|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|93.99||||93.99|64.85|64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93.99||||93.99||64.85|13.16
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|93.99||||93.99|0|64.85|13.16
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AARP [1000]|AARP [100000]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|51.56||||51.56|23.2|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AMBETTER [2930]|AMBETTER [293000]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.56||||51.56|25.78|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.56||||51.56|20.62|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.56||||51.56|20.62|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.56||||51.56|24.23|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.56||||51.56|21.14|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|CIGNA [1260]|CIGNA PPO [126025]|51.56||||51.56|20.62|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.56||||51.56|25.78|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.56||||51.56|23.2|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.56||||51.56|23.2|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|Self-pay|Self-pay|51.56||||51.56|10.31|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|TML [1980]|TML [198000]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.56||||51.56|7.22|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|UNICARE [2040]|UNICARE [204000]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.56||||51.56|0|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|WEB TPA [2115]|WEB TPA [211500]|51.56||||51.56|35.58|35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.56||||51.56||35.58|7.22
130688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML (1 ML) INJECTION SYRINGE|1 mL|WORKER'S COMP [2125]|TML WC [212537]|51.56||||51.56|0|35.58|7.22
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.93||||3.93|1.77|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.93||||3.93|1.97|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.93||||3.93|1.57|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.93||||3.93|1.57|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.93||||3.93|1.85|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.93||||3.93|1.61|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.93||||3.93|1.57|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.93||||3.93|1.97|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.93||||3.93|1.77|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.93||||3.93|1.77|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|3.93||||3.93|0.79|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.93||||3.93|0.55|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.93||||3.93|0|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.93||||3.93|2.71|2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.93||||3.93||2.71|0.55
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.93||||3.93|0|2.71|0.55
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|6.14||||6.14|2.76|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.14||||6.14|3.07|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.14||||6.14|2.46|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.14||||6.14|2.46|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.14||||6.14|2.89|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.14||||6.14|2.52|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|6.14||||6.14|2.46|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.14||||6.14|3.07|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.14||||6.14|2.76|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.14||||6.14|2.76|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|6.14||||6.14|1.23|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.14||||6.14|0.86|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.14||||6.14|0|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|6.14||||6.14|4.24|4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.14||||6.14||4.24|0.86
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|6.14||||6.14|0|4.24|0.86
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|66.14||||66.14|29.76|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.14||||66.14|33.07|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.14||||66.14|26.46|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.14||||66.14|26.46|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.14||||66.14|31.09|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.14||||66.14|27.12|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|66.14||||66.14|26.46|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.14||||66.14|33.07|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.14||||66.14|29.76|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.14||||66.14|29.76|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|66.14||||66.14|13.23|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.14||||66.14|9.26|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.14||||66.14|0|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|66.14||||66.14|45.64|45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.14||||66.14||45.64|9.26
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|66.14||||66.14|0|45.64|9.26
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|145.6||||145.6|65.52|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.6||||145.6|72.8|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.6||||145.6|58.24|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.6||||145.6|58.24|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.6||||145.6|68.43|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.6||||145.6|59.7|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|145.6||||145.6|58.24|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.6||||145.6|72.8|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.6||||145.6|65.52|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.6||||145.6|65.52|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|145.6||||145.6|29.12|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.6||||145.6|20.38|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.6||||145.6|0|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|145.6||||145.6|100.46|100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.6||||145.6||100.46|20.38
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|145.6||||145.6|0|100.46|20.38
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|42.24||||42.24|19.01|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|42.24||||42.24|21.12|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.24||||42.24|16.9|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.24||||42.24|16.9|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.24||||42.24|19.85|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|42.24||||42.24|17.32|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|42.24||||42.24|16.9|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|42.24||||42.24|21.12|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.24||||42.24|19.01|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.24||||42.24|19.01|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|Self-pay|Self-pay|42.24||||42.24|8.45|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.24||||42.24|5.91|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.24||||42.24|0|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|42.24||||42.24|29.15|29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.24||||42.24||29.15|5.91
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|42.24||||42.24|0|29.15|5.91
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.82||||0.82|0.37|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.82||||0.82|0.41|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.82||||0.82|0.33|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.82||||0.82|0.33|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.82||||0.82|0.39|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.82||||0.82|0.34|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.82||||0.82|0.33|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.82||||0.82|0.41|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.82||||0.82|0.37|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.82||||0.82|0.37|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|Self-pay|Self-pay|0.82||||0.82|0.16|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.82||||0.82|0.11|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.82||||0.82|0|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.82||||0.82|0.57|0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.82||||0.82||0.57|0.11
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.82||||0.82|0|0.57|0.11
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|16.31||||16.31|7.34|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.31||||16.31|8.16|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.31||||16.31|6.52|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.31||||16.31|6.52|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.31||||16.31|7.67|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.31||||16.31|6.69|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|16.31||||16.31|6.52|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.31||||16.31|8.16|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.31||||16.31|7.34|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.31||||16.31|7.34|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|16.31||||16.31|3.26|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.31||||16.31|2.28|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.31||||16.31|0|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|16.31||||16.31|11.25|11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.31||||16.31||11.25|2.28
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|16.31||||16.31|0|11.25|2.28
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.38||||15.38|6.92|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.38||||15.38|7.69|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.38||||15.38|6.15|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.38||||15.38|6.15|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.38||||15.38|7.23|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.38||||15.38|6.31|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.38||||15.38|6.15|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.38||||15.38|7.69|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.38||||15.38|6.92|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.38||||15.38|6.92|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|Self-pay|Self-pay|15.38||||15.38|3.08|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.38||||15.38|2.15|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.38||||15.38|0|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.38||||15.38|10.61|10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.38||||15.38||10.61|2.15
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.38||||15.38|0|10.61|2.15
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AARP [1000]|AARP [100000]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AETNA [1015]|AETNA [101529]|825||||825|371.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AMBETTER [2930]|AMBETTER [293000]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|825||||825|412.5|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|825||||825|330|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|825||||825|330|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|825||||825|387.75|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|825||||825|338.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|CIGNA [1260]|CIGNA PPO [126025]|825||||825|330|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|825||||825|412.5|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|825||||825|371.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|825||||825|371.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|Self-pay|Self-pay|825||||825|165|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|TML [1980]|TML [198000]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|825||||825|115.5|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|UNICARE [2040]|UNICARE [204000]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|825||||825|0|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|WEB TPA [2115]|WEB TPA [211500]|825||||825|569.25|569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|825||||825||569.25|115.5
134048|ERX|0250 - PHARMACY-GENERAL|NALOXONE 4 MG/ACTUATION NASAL SPRAY|1 each|WORKER'S COMP [2125]|TML WC [212537]|825||||825|0|569.25|115.5
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|91.88||||91.88|41.35|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMBETTER [2930]|AMBETTER [293000]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|91.88||||91.88|45.94|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|91.88||||91.88|36.75|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91.88||||91.88|36.75|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|91.88||||91.88|43.18|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|91.88||||91.88|37.67|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA PPO [126025]|91.88||||91.88|36.75|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|91.88||||91.88|45.94|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91.88||||91.88|41.35|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91.88||||91.88|41.35|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|Self-pay|Self-pay|91.88||||91.88|18.38|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|TML [1980]|TML [198000]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|91.88||||91.88|12.86|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNICARE [2040]|UNICARE [204000]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91.88||||91.88|0|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WEB TPA [2115]|WEB TPA [211500]|91.88||||91.88|63.4|63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|91.88||||91.88||63.4|12.86
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TML WC [212537]|91.88||||91.88|0|63.4|12.86
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.76||||6.76|3.04|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.76||||6.76|3.38|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.76||||6.76|2.7|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.76||||6.76|2.7|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.76||||6.76|3.18|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.76||||6.76|2.77|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.76||||6.76|2.7|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.76||||6.76|3.38|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.76||||6.76|3.04|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.76||||6.76|3.04|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|6.76||||6.76|1.35|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.76||||6.76|0.95|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.76||||6.76|0|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.76||||6.76|4.66|4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.76||||6.76||4.66|0.95
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.76||||6.76|0|4.66|0.95
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AARP [1000]|AARP [100000]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AETNA [1015]|AETNA [101529]|52.47||||52.47|23.61|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.47||||52.47|26.24|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.47||||52.47|20.99|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.47||||52.47|20.99|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.47||||52.47|24.66|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.47||||52.47|21.51|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|52.47||||52.47|20.99|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.47||||52.47|26.24|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.47||||52.47|23.61|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.47||||52.47|23.61|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|Self-pay|Self-pay|52.47||||52.47|10.49|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|TML [1980]|TML [198000]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.47||||52.47|7.35|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.47||||52.47|0|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|52.47||||52.47|36.2|36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.47||||52.47||36.2|7.35
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|52.47||||52.47|0|36.2|7.35
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.89||||13.89|6.25|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.89||||13.89|6.95|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.89||||13.89|5.56|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.89||||13.89|5.56|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.89||||13.89|6.53|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.89||||13.89|5.69|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.89||||13.89|5.56|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.89||||13.89|6.95|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.89||||13.89|6.25|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.89||||13.89|6.25|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|13.89||||13.89|2.78|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.89||||13.89|1.94|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.89||||13.89|0|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.89||||13.89|9.58|9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.89||||13.89||9.58|1.94
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.89||||13.89|0|9.58|1.94
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.59||||1.59|0.72|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.59||||1.59|0.8|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.59||||1.59|0.64|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.59||||1.59|0.64|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.59||||1.59|0.75|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.59||||1.59|0.65|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.59||||1.59|0.64|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.59||||1.59|0.8|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.59||||1.59|0.72|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.59||||1.59|0.72|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|Self-pay|Self-pay|1.59||||1.59|0.32|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.59||||1.59|0.22|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.59||||1.59|0|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.59||||1.59|1.1|1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.59||||1.59||1.1|0.22
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.59||||1.59|0|1.1|0.22
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.46||||2.46|1.11|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.46||||2.46|1.23|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.46||||2.46|0.98|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.46||||2.46|0.98|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.46||||2.46|1.16|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.46||||2.46|1.01|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.46||||2.46|0.98|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.46||||2.46|1.23|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.46||||2.46|1.11|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.46||||2.46|1.11|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.46||||2.46|0.49|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.46||||2.46|0.34|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.46||||2.46|0|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.46||||2.46|1.7|1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.46||||2.46||1.7|0.34
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.46||||2.46|0|1.7|0.34
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.54||||2.54|1.14|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.54||||2.54|1.27|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.54||||2.54|1.02|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.54||||2.54|1.02|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.54||||2.54|1.19|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.54||||2.54|1.04|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.54||||2.54|1.02|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.54||||2.54|1.27|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.54||||2.54|1.14|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.54||||2.54|1.14|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|2.54||||2.54|0.51|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.54||||2.54|0.36|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.54||||2.54|0|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.54||||2.54|1.75|1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.54||||2.54||1.75|0.36
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.54||||2.54|0|1.75|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.79||||1.79|0.81|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.79||||1.79|0.9|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.79||||1.79|0.72|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.79||||1.79|0.72|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.79||||1.79|0.84|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.79||||1.79|0.73|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.79||||1.79|0.72|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.79||||1.79|0.9|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.79||||1.79|0.81|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.79||||1.79|0.81|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|1.79||||1.79|0.36|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.79||||1.79|0.25|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.79||||1.79|0|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.79||||1.79|1.24|1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.79||||1.79||1.24|0.25
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.79||||1.79|0|1.24|0.25
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|18.06||||18.06|8.13|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.06||||18.06|9.03|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.06||||18.06|7.22|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.06||||18.06|7.22|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.06||||18.06|8.49|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.06||||18.06|7.4|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|18.06||||18.06|7.22|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.06||||18.06|9.03|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.06||||18.06|8.13|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.06||||18.06|8.13|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|18.06||||18.06|3.61|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TML [1980]|TML [198000]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.06||||18.06|2.53|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.06||||18.06|0|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|18.06||||18.06|12.46|12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.06||||18.06||12.46|2.53
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|18.06||||18.06|0|12.46|2.53
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AARP [1000]|AARP [100000]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|448.67||||448.67|201.9|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMBETTER [2930]|AMBETTER [293000]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|448.67||||448.67|224.34|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|448.67||||448.67|179.47|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|448.67||||448.67|179.47|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|448.67||||448.67|210.87|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|448.67||||448.67|183.95|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA [1260]|CIGNA PPO [126025]|448.67||||448.67|179.47|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|448.67||||448.67|224.34|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|448.67||||448.67|201.9|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|448.67||||448.67|201.9|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|Self-pay|Self-pay|448.67||||448.67|89.73|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|TML [1980]|TML [198000]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|448.67||||448.67|62.81|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNICARE [2040]|UNICARE [204000]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|448.67||||448.67|0|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WEB TPA [2115]|WEB TPA [211500]|448.67||||448.67|309.58|309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|448.67||||448.67||309.58|62.81
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WORKER'S COMP [2125]|TML WC [212537]|448.67||||448.67|0|309.58|62.81
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|21.12||||21.12|9.5|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.12||||21.12|10.56|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|8.45|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|8.45|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|9.93|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.12||||21.12|8.66|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|21.12||||21.12|8.45|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.12||||21.12|10.56|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|9.5|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|9.5|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|21.12||||21.12|4.22|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|2.96|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12|0|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|21.12||||21.12|14.57|14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12||14.57|2.96
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|21.12||||21.12|0|14.57|2.96
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.38||||2.38|1.07|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|0.95|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|0.95|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.12|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|0.98|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|1.07|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|1.07|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.38||||2.38|0.48|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.33|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38|0|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.38||||2.38||1.64|0.33
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.38||||2.38|1.07|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|0.95|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|0.95|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.12|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|0.98|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|1.07|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|1.07|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.38||||2.38|0.48|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.33|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38|0|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.38||||2.38||1.64|0.33
14553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38|0|1.64|0.33
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|4.27||||4.27|1.92|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.27||||4.27|2.14|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.27||||4.27|1.71|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.27||||4.27|1.71|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.27||||4.27|2.01|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.27||||4.27|1.75|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.27||||4.27|1.71|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.27||||4.27|2.14|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.27||||4.27|1.92|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.27||||4.27|1.92|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|4.27||||4.27|0.85|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.27||||4.27|0.6|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.27||||4.27|0|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.27||||4.27|2.95|2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.27||||4.27||2.95|0.6
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.27||||4.27|0|2.95|0.6
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|7.49||||7.49|3.37|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.49||||7.49|3.75|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.49||||7.49|3|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.49||||7.49|3|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.49||||7.49|3.52|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.49||||7.49|3.07|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.49||||7.49|3|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.49||||7.49|3.75|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.49||||7.49|3.37|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.49||||7.49|3.37|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|7.49||||7.49|1.5|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.49||||7.49|1.05|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.49||||7.49|0|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.49||||7.49|5.17|5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.49||||7.49||5.17|1.05
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.49||||7.49|0|5.17|1.05
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.72||||1.72|0.77|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.72||||1.72|0.86|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.72||||1.72|0.69|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.72||||1.72|0.69|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.72||||1.72|0.81|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.72||||1.72|0.71|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.72||||1.72|0.69|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.72||||1.72|0.86|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.72||||1.72|0.77|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.72||||1.72|0.77|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.72||||1.72|0.34|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.72||||1.72|0.24|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.72||||1.72|0|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.72||||1.72|1.19|1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.72||||1.72||1.19|0.24
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.72||||1.72|0|1.19|0.24
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AARP [1000]|AARP [100000]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AETNA [1015]|AETNA [101529]|40.4||||40.4|18.18|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMBETTER [2930]|AMBETTER [293000]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40.4||||40.4|20.2|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.4||||40.4|16.16|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.4||||40.4|16.16|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.4||||40.4|18.99|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40.4||||40.4|16.56|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA [1260]|CIGNA PPO [126025]|40.4||||40.4|16.16|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40.4||||40.4|20.2|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.4||||40.4|18.18|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.4||||40.4|18.18|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|Self-pay|Self-pay|40.4||||40.4|8.08|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|TML [1980]|TML [198000]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.4||||40.4|5.66|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UNICARE [2040]|UNICARE [204000]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.4||||40.4|0|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WEB TPA [2115]|WEB TPA [211500]|40.4||||40.4|27.88|27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.4||||40.4||27.88|5.66
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WORKER'S COMP [2125]|TML WC [212537]|40.4||||40.4|0|27.88|5.66
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.87||||2.87|1.29|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.87||||2.87|1.44|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.87||||2.87|1.15|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.87||||2.87|1.15|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.87||||2.87|1.35|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.87||||2.87|1.18|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.87||||2.87|1.15|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.87||||2.87|1.44|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.87||||2.87|1.29|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.87||||2.87|1.29|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|Self-pay|Self-pay|2.87||||2.87|0.57|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.87||||2.87|0.4|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.87||||2.87|0|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.87||||2.87|1.98|1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.87||||2.87||1.98|0.4
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.87||||2.87|0|1.98|0.4
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.58||||2.58|1.16|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.58||||2.58|1.29|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.58||||2.58|1.03|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.58||||2.58|1.03|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.58||||2.58|1.21|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.58||||2.58|1.06|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.58||||2.58|1.03|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.58||||2.58|1.29|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.58||||2.58|1.16|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.58||||2.58|1.16|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|Self-pay|Self-pay|2.58||||2.58|0.52|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.58||||2.58|0.36|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.58||||2.58|0|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.58||||2.58|1.78|1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.58||||2.58||1.78|0.36
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.58||||2.58|0|1.78|0.36
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.37||||8.37|3.77|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.37||||8.37|4.19|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.37||||8.37|3.35|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.37||||8.37|3.35|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.37||||8.37|3.93|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.37||||8.37|3.43|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.37||||8.37|3.35|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.37||||8.37|4.19|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.37||||8.37|3.77|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.37||||8.37|3.77|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|8.37||||8.37|1.67|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.37||||8.37|1.17|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.37||||8.37|0|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.37||||8.37|5.78|5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.37||||8.37||5.78|1.17
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.37||||8.37|0|5.78|1.17
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.79||||6.79|3.06|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.79||||6.79|3.4|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.79||||6.79|2.72|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.79||||6.79|2.72|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.79||||6.79|3.19|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.79||||6.79|2.78|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.79||||6.79|2.72|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.79||||6.79|3.4|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.79||||6.79|3.06|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.79||||6.79|3.06|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|6.79||||6.79|1.36|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.79||||6.79|0.95|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.79||||6.79|0|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.79||||6.79|4.69|4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.79||||6.79||4.69|0.95
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.79||||6.79|0|4.69|0.95
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|79.2||||79.2|35.64|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|39.6|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.2||||79.2|31.68|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.2||||79.2|31.68|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.2||||79.2|37.22|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|32.47|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|39.6|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|35.64|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|35.64|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|79.2||||79.2|15.84|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|TML [1980]|TML [198000]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.2||||79.2|11.09|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.2||||79.2|0|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.2||||79.2||54.65|11.09
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2|0|54.65|11.09
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|17.82||||17.82|8.02|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.82||||17.82|8.91|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.82||||17.82|7.13|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.82||||17.82|7.13|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.82||||17.82|8.38|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.82||||17.82|7.31|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|17.82||||17.82|7.13|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.82||||17.82|8.91|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.82||||17.82|8.02|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.82||||17.82|8.02|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|Self-pay|Self-pay|17.82||||17.82|3.56|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.82||||17.82|2.49|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.82||||17.82|0|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|17.82||||17.82|12.3|12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.82||||17.82||12.3|2.49
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|17.82||||17.82|0|12.3|2.49
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|6.01||||6.01|2.7|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.01||||6.01|3.01|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.01||||6.01|2.4|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.01||||6.01|2.4|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.01||||6.01|2.82|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.01||||6.01|2.46|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.01||||6.01|2.4|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.01||||6.01|3.01|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.01||||6.01|2.7|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.01||||6.01|2.7|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|6.01||||6.01|1.2|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.01||||6.01|0.84|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.01||||6.01|0|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.01||||6.01|4.15|4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.01||||6.01||4.15|0.84
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.01||||6.01|0|4.15|0.84
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|419.62||||419.62|188.83|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|419.62||||419.62|209.81|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419.62||||419.62|167.85|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419.62||||419.62|167.85|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419.62||||419.62|197.22|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|419.62||||419.62|172.04|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|419.62||||419.62|167.85|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|419.62||||419.62|209.81|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419.62||||419.62|188.83|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419.62||||419.62|188.83|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|419.62||||419.62|83.92|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419.62||||419.62|58.75|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419.62||||419.62|0|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|419.62||||419.62|289.54|289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419.62||||419.62||289.54|58.75
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|419.62||||419.62|0|289.54|58.75
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|8.86||||8.86|3.99|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.86||||8.86|4.43|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.86||||8.86|3.54|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.86||||8.86|3.54|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.86||||8.86|4.16|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.86||||8.86|3.63|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.86||||8.86|3.54|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.86||||8.86|4.43|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.86||||8.86|3.99|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.86||||8.86|3.99|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|8.86||||8.86|1.77|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.86||||8.86|1.24|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.86||||8.86|0|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.86||||8.86|6.11|6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.86||||8.86||6.11|1.24
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.86||||8.86|0|6.11|1.24
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.67|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.38|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.38|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|2.79|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|2.44|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.67|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.67|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|5.94||||5.94|1.19|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|0.83|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94|0|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|0.83
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94|0|4.1|0.83
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AARP [1000]|AARP [100000]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AETNA [1015]|AETNA [101529]|988.28||||988.28|444.73|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMBETTER [2930]|AMBETTER [293000]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|988.28||||988.28|494.14|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|988.28||||988.28|395.31|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|988.28||||988.28|395.31|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|988.28||||988.28|464.49|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|988.28||||988.28|405.19|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA [1260]|CIGNA PPO [126025]|988.28||||988.28|395.31|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|988.28||||988.28|494.14|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|988.28||||988.28|444.73|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|988.28||||988.28|444.73|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|Self-pay|Self-pay|988.28||||988.28|197.66|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|TML [1980]|TML [198000]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|988.28||||988.28|138.36|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNICARE [2040]|UNICARE [204000]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|988.28||||988.28|0|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WEB TPA [2115]|WEB TPA [211500]|988.28||||988.28|681.91|681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|988.28||||988.28||681.91|138.36
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WORKER'S COMP [2125]|TML WC [212537]|988.28||||988.28|0|681.91|138.36
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.01||||10.01|4.5|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.01||||10.01|5.01|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.01||||10.01|4|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.01||||10.01|4|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.01||||10.01|4.7|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.01||||10.01|4.1|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.01||||10.01|4|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.01||||10.01|5.01|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.01||||10.01|4.5|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.01||||10.01|4.5|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|10.01||||10.01|2|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.01||||10.01|1.4|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.01||||10.01|0|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.01||||10.01|6.91|6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.01||||10.01||6.91|1.4
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.01||||10.01|0|6.91|1.4
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.1||||1.1|0.5|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.1||||1.1|0.55|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.1||||1.1|0.44|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.1||||1.1|0.44|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.1||||1.1|0.52|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.1||||1.1|0.45|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.1||||1.1|0.44|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.1||||1.1|0.55|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.1||||1.1|0.5|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.1||||1.1|0.5|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.1||||1.1|0.22|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.1||||1.1|0.15|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.1||||1.1|0|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.1||||1.1|0.76|0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.1||||1.1||0.76|0.15
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.1||||1.1|0|0.76|0.15
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AARP [1000]|AARP [100000]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AETNA [1015]|AETNA [101529]|198||||198|89.1|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AMBETTER [2930]|AMBETTER [293000]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|99|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|198||||198|79.2|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|198||||198|79.2|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|198||||198|93.06|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|198||||198|81.18|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA [1260]|CIGNA PPO [126025]|198||||198|79.2|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|99|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|89.1|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|89.1|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|Self-pay|Self-pay|198||||198|39.6|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|TML [1980]|TML [198000]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|198||||198|27.72|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UNICARE [2040]|UNICARE [204000]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198|0|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|198||||198||136.62|27.72
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WORKER'S COMP [2125]|TML WC [212537]|198||||198|0|136.62|27.72
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|75.63||||75.63|34.03|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.63||||75.63|37.82|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.63||||75.63|30.25|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.63||||75.63|30.25|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.63||||75.63|35.55|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.63||||75.63|31.01|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|75.63||||75.63|30.25|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.63||||75.63|37.82|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.63||||75.63|34.03|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.63||||75.63|34.03|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|75.63||||75.63|15.13|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.63||||75.63|10.59|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.63||||75.63|0|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|75.63||||75.63|52.18|52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.63||||75.63||52.18|10.59
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|75.63||||75.63|0|52.18|10.59
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|181.07||||181.07|81.48|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.07||||181.07|90.54|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.07||||181.07|72.43|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.07||||181.07|72.43|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.07||||181.07|85.1|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.07||||181.07|74.24|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|181.07||||181.07|72.43|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.07||||181.07|90.54|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.07||||181.07|81.48|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.07||||181.07|81.48|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|Self-pay|Self-pay|181.07||||181.07|36.21|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|TML [1980]|TML [198000]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.07||||181.07|25.35|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.07||||181.07|0|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|181.07||||181.07|124.94|124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.07||||181.07||124.94|25.35
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|181.07||||181.07|0|124.94|25.35
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|108.9||||108.9|49.01|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108.9||||108.9|54.45|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.9||||108.9|43.56|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.9||||108.9|43.56|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.9||||108.9|51.18|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108.9||||108.9|44.65|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|108.9||||108.9|43.56|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108.9||||108.9|54.45|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.9||||108.9|49.01|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.9||||108.9|49.01|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|Self-pay|Self-pay|108.9||||108.9|21.78|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|TML [1980]|TML [198000]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.9||||108.9|15.25|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNICARE [2040]|UNICARE [204000]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.9||||108.9|0|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|108.9||||108.9|75.14|75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.9||||108.9||75.14|15.25
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|108.9||||108.9|0|75.14|15.25
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|118.8||||118.8|53.46|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.8||||118.8|59.4|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.8||||118.8|47.52|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.8||||118.8|47.52|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.8||||118.8|55.84|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.8||||118.8|48.71|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|118.8||||118.8|47.52|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.8||||118.8|59.4|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.8||||118.8|53.46|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.8||||118.8|53.46|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|118.8||||118.8|23.76|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|TML [1980]|TML [198000]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.8||||118.8|16.63|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|UNICARE [2040]|UNICARE [204000]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.8||||118.8|0|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|118.8||||118.8|81.97|81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.8||||118.8||81.97|16.63
16014|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|118.8||||118.8|0|81.97|16.63
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.28||||17.28|7.78|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.28||||17.28|8.64|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.28||||17.28|6.91|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.28||||17.28|6.91|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.28||||17.28|8.12|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.28||||17.28|7.08|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.28||||17.28|6.91|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.28||||17.28|8.64|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.28||||17.28|7.78|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.28||||17.28|7.78|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|17.28||||17.28|3.46|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|TML [1980]|TML [198000]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.28||||17.28|2.42|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.28||||17.28|0|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.28||||17.28|11.92|11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.28||||17.28||11.92|2.42
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.28||||17.28|0|11.92|2.42
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AARP [1000]|AARP [100000]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AETNA [1015]|AETNA [101529]|475.2||||475.2|213.84|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMBETTER [2930]|AMBETTER [293000]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|475.2||||475.2|237.6|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|475.2||||475.2|190.08|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|475.2||||475.2|190.08|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|475.2||||475.2|223.34|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|475.2||||475.2|194.83|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA PPO [126025]|475.2||||475.2|190.08|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|475.2||||475.2|237.6|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|475.2||||475.2|213.84|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|475.2||||475.2|213.84|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|Self-pay|Self-pay|475.2||||475.2|95.04|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|TML [1980]|TML [198000]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|475.2||||475.2|66.53|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UNICARE [2040]|UNICARE [204000]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|475.2||||475.2|0|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WEB TPA [2115]|WEB TPA [211500]|475.2||||475.2|327.89|327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|475.2||||475.2||327.89|66.53
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TML WC [212537]|475.2||||475.2|0|327.89|66.53
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|97.68||||97.68|43.96|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.68||||97.68|48.84|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97.68||||97.68|39.07|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.68||||97.68|39.07|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97.68||||97.68|45.91|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97.68||||97.68|40.05|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|97.68||||97.68|39.07|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.68||||97.68|48.84|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.68||||97.68|43.96|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.68||||97.68|43.96|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|97.68||||97.68|19.54|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97.68||||97.68|13.68|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.68||||97.68|0|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|97.68||||97.68|67.4|67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97.68||||97.68||67.4|13.68
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|97.68||||97.68|0|67.4|13.68
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.96||||11.96|5.38|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.96||||11.96|5.98|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.96||||11.96|4.78|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.96||||11.96|4.78|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.96||||11.96|5.62|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.96||||11.96|4.9|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.96||||11.96|4.78|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.96||||11.96|5.98|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.96||||11.96|5.38|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.96||||11.96|5.38|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|11.96||||11.96|2.39|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.96||||11.96|1.67|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.96||||11.96|0|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.96||||11.96|8.25|8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.96||||11.96||8.25|1.67
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.96||||11.96|0|8.25|1.67
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.01||||7.01|3.15|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.01||||7.01|3.51|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.01||||7.01|2.8|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.01||||7.01|2.8|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.01||||7.01|3.29|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.01||||7.01|2.87|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.01||||7.01|2.8|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.01||||7.01|3.51|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.01||||7.01|3.15|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.01||||7.01|3.15|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.01||||7.01|1.4|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.01||||7.01|0.98|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.01||||7.01|0|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.01||||7.01|4.84|4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.01||||7.01||4.84|0.98
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.01||||7.01|0|4.84|0.98
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.49||||8.49|3.82|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.49||||8.49|4.25|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.49||||8.49|3.4|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.49||||8.49|3.4|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.49||||8.49|3.99|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.49||||8.49|3.48|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.49||||8.49|3.4|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.49||||8.49|4.25|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.49||||8.49|3.82|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.49||||8.49|3.82|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.49||||8.49|1.7|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.49||||8.49|1.19|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.49||||8.49|0|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.49||||8.49|5.86|5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.49||||8.49||5.86|1.19
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.49||||8.49|0|5.86|1.19
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AARP [1000]|AARP [100000]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.48|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMBETTER [2930]|AMBETTER [293000]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.29||||23.29|11.65|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|9.32|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|9.32|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|10.95|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.29||||23.29|9.55|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA PPO [126025]|23.29||||23.29|9.32|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.29||||23.29|11.65|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.48|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.48|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|Self-pay|Self-pay|23.29||||23.29|4.66|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|TML [1980]|TML [198000]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|3.26|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNICARE [2040]|UNICARE [204000]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29|0|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WEB TPA [2115]|WEB TPA [211500]|23.29||||23.29|16.07|16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|3.26
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TML WC [212537]|23.29||||23.29|0|16.07|3.26
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.15||||7.15|3.22|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.15||||7.15|3.58|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.15||||7.15|2.86|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.15||||7.15|2.86|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.15||||7.15|3.36|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.15||||7.15|2.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.15||||7.15|2.86|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.15||||7.15|3.58|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.15||||7.15|3.22|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.15||||7.15|3.22|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|Self-pay|Self-pay|7.15||||7.15|1.43|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.15||||7.15|1|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.15||||7.15|0|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.15||||7.15|4.93|4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.15||||7.15||4.93|1
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.15||||7.15|0|4.93|1
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|75.24||||75.24|33.86|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.24||||75.24|37.62|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.24||||75.24|30.1|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.24||||75.24|30.1|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.24||||75.24|35.36|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.24||||75.24|30.85|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|75.24||||75.24|30.1|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.24||||75.24|37.62|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.24||||75.24|33.86|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.24||||75.24|33.86|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|75.24||||75.24|15.05|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.24||||75.24|10.53|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.24||||75.24|0|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|75.24||||75.24|51.92|51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.24||||75.24||51.92|10.53
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|75.24||||75.24|0|51.92|10.53
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|129.36||||129.36|58.21|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|129.36||||129.36|64.68|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.36||||129.36|51.74|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.36||||129.36|51.74|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.36||||129.36|60.8|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|129.36||||129.36|53.04|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|129.36||||129.36|51.74|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|129.36||||129.36|64.68|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.36||||129.36|58.21|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.36||||129.36|58.21|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|129.36||||129.36|25.87|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.36||||129.36|18.11|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.36||||129.36|0|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|129.36||||129.36|89.26|89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.36||||129.36||89.26|18.11
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|129.36||||129.36|0|89.26|18.11
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|13.72||||13.72|6.17|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.72||||13.72|6.86|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.72||||13.72|5.49|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.72||||13.72|5.49|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.72||||13.72|6.45|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.72||||13.72|5.63|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.72||||13.72|5.49|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.72||||13.72|6.86|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.72||||13.72|6.17|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.72||||13.72|6.17|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|13.72||||13.72|2.74|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.72||||13.72|1.92|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.72||||13.72|0|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.72||||13.72|9.47|9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.72||||13.72||9.47|1.92
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.72||||13.72|0|9.47|1.92
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.43||||0.43|0.19|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.43||||0.43|0.22|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.43||||0.43|0.17|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.43||||0.43|0.17|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.43||||0.43|0.2|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.43||||0.43|0.18|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.43||||0.43|0.17|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.43||||0.43|0.22|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.43||||0.43|0.19|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.43||||0.43|0.19|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|0.43||||0.43|0.09|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.43||||0.43|0.06|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.43||||0.43|0|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.43||||0.43|0.3|0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.43||||0.43||0.3|0.06
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.43||||0.43|0|0.3|0.06
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AARP [1000]|AARP [100000]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AETNA [1015]|AETNA [101529]|44.25||||44.25|19.91|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMBETTER [2930]|AMBETTER [293000]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.25||||44.25|22.13|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.25||||44.25|17.7|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.25||||44.25|17.7|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.25||||44.25|20.8|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.25||||44.25|18.14|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|44.25||||44.25|17.7|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.25||||44.25|22.13|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.25||||44.25|19.91|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.25||||44.25|19.91|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|Self-pay|Self-pay|44.25||||44.25|8.85|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|TML [1980]|TML [198000]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.25||||44.25|6.2|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNICARE [2040]|UNICARE [204000]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.25||||44.25|0|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WEB TPA [2115]|WEB TPA [211500]|44.25||||44.25|30.53|30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.25||||44.25||30.53|6.2
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|44.25||||44.25|0|30.53|6.2
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|46.61||||46.61|20.97|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.61||||46.61|23.31|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.61||||46.61|18.64|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.61||||46.61|18.64|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.61||||46.61|21.91|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.61||||46.61|19.11|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|46.61||||46.61|18.64|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.61||||46.61|23.31|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.61||||46.61|20.97|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.61||||46.61|20.97|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|46.61||||46.61|9.32|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.61||||46.61|6.53|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.61||||46.61|0|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|46.61||||46.61|32.16|32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.61||||46.61||32.16|6.53
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|46.61||||46.61|0|32.16|6.53
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|84.14||||84.14|37.86|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84.14||||84.14|42.07|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.14||||84.14|33.66|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.14||||84.14|33.66|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.14||||84.14|39.55|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84.14||||84.14|34.5|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|84.14||||84.14|33.66|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84.14||||84.14|42.07|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.14||||84.14|37.86|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.14||||84.14|37.86|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|84.14||||84.14|16.83|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.14||||84.14|11.78|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.14||||84.14|0|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|84.14||||84.14|58.06|58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.14||||84.14||58.06|11.78
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|84.14||||84.14|0|58.06|11.78
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|25.26||||25.26|11.37|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.26||||25.26|12.63|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.26||||25.26|10.1|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.26||||25.26|10.1|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.26||||25.26|11.87|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.26||||25.26|10.36|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|25.26||||25.26|10.1|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.26||||25.26|12.63|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.26||||25.26|11.37|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.26||||25.26|11.37|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|25.26||||25.26|5.05|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.26||||25.26|3.54|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.26||||25.26|0|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|25.26||||25.26|17.43|17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.26||||25.26||17.43|3.54
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|25.26||||25.26|0|17.43|3.54
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.42||||3.42|1.54|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.42||||3.42|1.71|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.42||||3.42|1.37|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.42||||3.42|1.37|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.42||||3.42|1.61|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.42||||3.42|1.4|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.42||||3.42|1.37|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.42||||3.42|1.71|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.42||||3.42|1.54|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.42||||3.42|1.54|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|Self-pay|Self-pay|3.42||||3.42|0.68|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.42||||3.42|0.48|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.42||||3.42|0|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.42||||3.42|2.36|2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.42||||3.42||2.36|0.48
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.42||||3.42|0|2.36|0.48
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|93.72||||93.72|42.17|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93.72||||93.72|46.86|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93.72||||93.72|37.49|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93.72||||93.72|37.49|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93.72||||93.72|44.05|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93.72||||93.72|38.43|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|93.72||||93.72|37.49|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93.72||||93.72|46.86|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93.72||||93.72|42.17|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93.72||||93.72|42.17|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|93.72||||93.72|18.74|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93.72||||93.72|13.12|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93.72||||93.72|0|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|93.72||||93.72|64.67|64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93.72||||93.72||64.67|13.12
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|93.72||||93.72|0|64.67|13.12
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|16.9||||16.9|7.61|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.9||||16.9|8.45|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.9||||16.9|6.76|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.9||||16.9|6.76|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.9||||16.9|7.94|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.9||||16.9|6.93|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.9||||16.9|6.76|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.9||||16.9|8.45|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.9||||16.9|7.61|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.9||||16.9|7.61|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|16.9||||16.9|3.38|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.9||||16.9|2.37|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.9||||16.9|0|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.9||||16.9|11.66|11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.9||||16.9||11.66|2.37
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|16.9||||16.9|0|11.66|2.37
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.97||||8.97|4.04|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.97||||8.97|4.49|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.97||||8.97|3.59|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.97||||8.97|3.59|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.97||||8.97|4.22|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.97||||8.97|3.68|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.97||||8.97|3.59|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.97||||8.97|4.49|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.97||||8.97|4.04|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.97||||8.97|4.04|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|8.97||||8.97|1.79|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|TML [1980]|TML [198000]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.97||||8.97|1.26|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.97||||8.97|0|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.97||||8.97|6.19|6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.97||||8.97||6.19|1.26
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.97||||8.97|0|6.19|1.26
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AARP [1000]|AARP [100000]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AETNA [1015]|AETNA [101529]|132180||||132180|59481|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMBETTER [2930]|AMBETTER [293000]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132180||||132180|66090|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132180||||132180|52872|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132180||||132180|52872|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132180||||132180|62124.6|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132180||||132180|54193.8|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA [1260]|CIGNA PPO [126025]|132180||||132180|52872|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132180||||132180|66090|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132180||||132180|59481|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132180||||132180|59481|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|Self-pay|Self-pay|132180||||132180|26436|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|TML [1980]|TML [198000]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132180||||132180|18505.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNICARE [2040]|UNICARE [204000]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132180||||132180|0|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WEB TPA [2115]|WEB TPA [211500]|132180||||132180|91204.2|91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132180||||132180||91204.2|18505.2
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WORKER'S COMP [2125]|TML WC [212537]|132180||||132180|0|91204.2|18505.2
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AARP [1000]|AARP [100000]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AETNA [1015]|AETNA [101529]|192.38||||192.38|86.57|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMBETTER [2930]|AMBETTER [293000]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|192.38||||192.38|96.19|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|192.38||||192.38|76.95|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|192.38||||192.38|76.95|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|192.38||||192.38|90.42|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|192.38||||192.38|78.88|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|192.38||||192.38|76.95|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|192.38||||192.38|96.19|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|192.38||||192.38|86.57|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|192.38||||192.38|86.57|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|Self-pay|Self-pay|192.38||||192.38|38.48|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|TML [1980]|TML [198000]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|192.38||||192.38|26.93|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNICARE [2040]|UNICARE [204000]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|192.38||||192.38|0|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WEB TPA [2115]|WEB TPA [211500]|192.38||||192.38|132.74|132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|192.38||||192.38||132.74|26.93
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|192.38||||192.38|0|132.74|26.93
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AARP [1000]|AARP [100000]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AETNA [1015]|AETNA [101529]|50.27||||50.27|22.62|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMBETTER [2930]|AMBETTER [293000]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.27||||50.27|25.14|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.27||||50.27|20.11|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.27||||50.27|20.11|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.27||||50.27|23.63|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50.27||||50.27|20.61|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA [1260]|CIGNA PPO [126025]|50.27||||50.27|20.11|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.27||||50.27|25.14|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.27||||50.27|22.62|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.27||||50.27|22.62|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|Self-pay|Self-pay|50.27||||50.27|10.05|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|TML [1980]|TML [198000]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.27||||50.27|7.04|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNICARE [2040]|UNICARE [204000]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.27||||50.27|0|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WEB TPA [2115]|WEB TPA [211500]|50.27||||50.27|34.69|34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.27||||50.27||34.69|7.04
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WORKER'S COMP [2125]|TML WC [212537]|50.27||||50.27|0|34.69|7.04
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|101.22||||101.22|45.55|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101.22||||101.22|50.61|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101.22||||101.22|40.49|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101.22||||101.22|40.49|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101.22||||101.22|47.57|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|101.22||||101.22|41.5|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|101.22||||101.22|40.49|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101.22||||101.22|50.61|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101.22||||101.22|45.55|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101.22||||101.22|45.55|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|101.22||||101.22|20.24|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101.22||||101.22|14.17|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101.22||||101.22|0|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|101.22||||101.22|69.84|69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101.22||||101.22||69.84|14.17
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|101.22||||101.22|0|69.84|14.17
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AARP [1000]|AARP [100000]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AETNA [1015]|AETNA [101529]|47.26||||47.26|21.27|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.26||||47.26|23.63|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.26||||47.26|18.9|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.26||||47.26|18.9|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.26||||47.26|22.21|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|47.26||||47.26|19.38|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|47.26||||47.26|18.9|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.26||||47.26|23.63|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.26||||47.26|21.27|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.26||||47.26|21.27|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|Self-pay|Self-pay|47.26||||47.26|9.45|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|TML [1980]|TML [198000]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.26||||47.26|6.62|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.26||||47.26|0|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|47.26||||47.26|32.61|32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.26||||47.26||32.61|6.62
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|47.26||||47.26|0|32.61|6.62
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|582.39||||582.39|262.08|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|582.39||||582.39|291.2|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|582.39||||582.39|232.96|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|582.39||||582.39|232.96|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|582.39||||582.39|273.72|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|582.39||||582.39|238.78|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|582.39||||582.39|232.96|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|582.39||||582.39|291.2|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|582.39||||582.39|262.08|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|582.39||||582.39|262.08|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|582.39||||582.39|116.48|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|582.39||||582.39|81.53|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|582.39||||582.39|0|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|582.39||||582.39|401.85|401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|582.39||||582.39||401.85|81.53
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|582.39||||582.39|0|401.85|81.53
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1455.96||||1455.96|655.18|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1455.96||||1455.96|727.98|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1455.96||||1455.96|582.38|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1455.96||||1455.96|582.38|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1455.96||||1455.96|684.3|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1455.96||||1455.96|596.94|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|1455.96||||1455.96|582.38|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1455.96||||1455.96|727.98|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1455.96||||1455.96|655.18|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1455.96||||1455.96|655.18|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|1455.96||||1455.96|291.19|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1455.96||||1455.96|203.83|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1455.96||||1455.96|0|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|1455.96||||1455.96|1004.61|1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1455.96||||1455.96||1004.61|203.83
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|1455.96||||1455.96|0|1004.61|203.83
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|5823.84||||5823.84|2620.73|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5823.84||||5823.84|2911.92|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5823.84||||5823.84|2329.54|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5823.84||||5823.84|2329.54|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5823.84||||5823.84|2737.2|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5823.84||||5823.84|2387.77|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|5823.84||||5823.84|2911.92|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5823.84||||5823.84|2911.92|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5823.84||||5823.84|2620.73|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5823.84||||5823.84|2620.73|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|5823.84||||5823.84|1164.77|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5823.84||||5823.84|815.34|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5823.84||||5823.84|0|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|5823.84||||5823.84|4018.45|4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5823.84||||5823.84||4018.45|815.34
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|5823.84||||5823.84|0|4018.45|815.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|311.7||||311.7|140.27|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|311.7||||311.7|155.85|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311.7||||311.7|124.68|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311.7||||311.7|124.68|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311.7||||311.7|146.5|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|311.7||||311.7|127.8|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|311.7||||311.7|124.68|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|311.7||||311.7|155.85|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311.7||||311.7|140.27|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311.7||||311.7|140.27|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|311.7||||311.7|62.34|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311.7||||311.7|43.64|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311.7||||311.7|0|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|311.7||||311.7|215.07|215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|311.7||||311.7||215.07|43.64
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|311.7||||311.7|140.27|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|311.7||||311.7|155.85|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311.7||||311.7|124.68|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311.7||||311.7|124.68|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311.7||||311.7|146.5|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|311.7||||311.7|127.8|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|311.7||||311.7|124.68|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|311.7||||311.7|155.85|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311.7||||311.7|140.27|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311.7||||311.7|140.27|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|311.7||||311.7|62.34|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311.7||||311.7|43.64|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311.7||||311.7|0|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|311.7||||311.7|215.07|215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|311.7||||311.7||215.07|43.64
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|311.7||||311.7|0|215.07|43.64
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AARP [1000]|AARP [100000]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AETNA [1015]|AETNA [101529]|132||||132|59.4|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMBETTER [2930]|AMBETTER [293000]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|66|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|52.8|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|52.8|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|62.04|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|54.12|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|66|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|59.4|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|59.4|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|Self-pay|Self-pay|132||||132|26.4|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|TML [1980]|TML [198000]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|18.48|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNICARE [2040]|UNICARE [204000]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|0|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132||91.08|18.48
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WORKER'S COMP [2125]|TML WC [212537]|132||||132|0|91.08|18.48
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|264||||264|118.8|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMBETTER [2930]|AMBETTER [293000]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|132|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|105.6|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|105.6|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|124.08|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|108.24|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|132|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|118.8|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|118.8|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|264||||264|52.8|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|TML [1980]|TML [198000]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|36.96|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNICARE [2040]|UNICARE [204000]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264|0|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264||182.16|36.96
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|264||||264|0|182.16|36.96
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.8||||5.8|2.61|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.8||||5.8|2.9|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.8||||5.8|2.32|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.8||||5.8|2.32|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.8||||5.8|2.73|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.8||||5.8|2.38|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.8||||5.8|2.32|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.8||||5.8|2.9|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.8||||5.8|2.61|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.8||||5.8|2.61|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.8||||5.8|1.16|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.8||||5.8|0.81|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.8||||5.8|0|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.8||||5.8|4|4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.8||||5.8||4|0.81
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.8||||5.8|0|4|0.81
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|3626.04||||3626.04|1631.72|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3626.04||||3626.04|1813.02|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3626.04||||3626.04|1450.42|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3626.04||||3626.04|1450.42|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3626.04||||3626.04|1704.24|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3626.04||||3626.04|1486.68|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|3626.04||||3626.04|1450.42|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3626.04||||3626.04|1813.02|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3626.04||||3626.04|1631.72|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3626.04||||3626.04|1631.72|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|Self-pay|Self-pay|3626.04||||3626.04|725.21|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|TML [1980]|TML [198000]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3626.04||||3626.04|507.65|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|3626.04||||3626.04|2501.97|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3626.04||||3626.04||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|3626.04||||3626.04|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|1087.82||||1087.82|489.52|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1087.82||||1087.82|543.91|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1087.82||||1087.82|435.13|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1087.82||||1087.82|435.13|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1087.82||||1087.82|511.28|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1087.82||||1087.82|446.01|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|1087.82||||1087.82|435.13|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1087.82||||1087.82|543.91|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1087.82||||1087.82|489.52|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1087.82||||1087.82|489.52|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|Self-pay|Self-pay|1087.82||||1087.82|217.56|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|TML [1980]|TML [198000]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1087.82||||1087.82|152.29|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1087.82||||1087.82|0|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|1087.82||||1087.82|750.6|2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1087.82||||1087.82||2501.97|152.29
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|1087.82||||1087.82|0|2501.97|152.29
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|108.35||||108.35|48.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108.35||||108.35|54.18|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.35||||108.35|43.34|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.35||||108.35|43.34|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.35||||108.35|50.92|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108.35||||108.35|44.42|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|108.35||||108.35|43.34|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108.35||||108.35|54.18|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.35||||108.35|48.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.35||||108.35|48.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|108.35||||108.35|21.67|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.35||||108.35|15.17|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.35||||108.35|0|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|108.35||||108.35|74.76|74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.35||||108.35||74.76|15.17
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|108.35||||108.35|0|74.76|15.17
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AARP [1000]|AARP [100000]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AETNA [1015]|AETNA [101529]|392.84||||392.84|176.78|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMBETTER [2930]|AMBETTER [293000]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|392.84||||392.84|196.42|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|392.84||||392.84|157.14|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|392.84||||392.84|157.14|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|392.84||||392.84|184.63|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|392.84||||392.84|161.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA [1260]|CIGNA PPO [126025]|392.84||||392.84|157.14|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|392.84||||392.84|196.42|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|392.84||||392.84|176.78|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|392.84||||392.84|176.78|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|Self-pay|Self-pay|392.84||||392.84|78.57|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|TML [1980]|TML [198000]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|392.84||||392.84|55|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UNICARE [2040]|UNICARE [204000]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|392.84||||392.84|0|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WEB TPA [2115]|WEB TPA [211500]|392.84||||392.84|271.06|271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|392.84||||392.84||271.06|55
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WORKER'S COMP [2125]|TML WC [212537]|392.84||||392.84|0|271.06|55
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.17||||3.17|1.43|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.17||||3.17|1.59|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.17||||3.17|1.27|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.17||||3.17|1.27|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.17||||3.17|1.49|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.17||||3.17|1.3|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.17||||3.17|1.27|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.17||||3.17|1.59|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.17||||3.17|1.43|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.17||||3.17|1.43|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|Self-pay|Self-pay|3.17||||3.17|0.63|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.17||||3.17|0.44|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.17||||3.17|0|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.17||||3.17|2.19|2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.17||||3.17||2.19|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.17||||3.17|0|2.19|0.44
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AARP [1000]|AARP [100000]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|105.6||||105.6|47.52|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.6||||105.6|52.8|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.6||||105.6|42.24|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.6||||105.6|42.24|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.6||||105.6|49.63|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|105.6||||105.6|43.3|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|105.6||||105.6|42.24|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.6||||105.6|52.8|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.6||||105.6|47.52|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.6||||105.6|47.52|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|Self-pay|Self-pay|105.6||||105.6|21.12|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|TML [1980]|TML [198000]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.6||||105.6|14.78|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.6||||105.6|0|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|105.6||||105.6|72.86|72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.6||||105.6||72.86|14.78
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|105.6||||105.6|0|72.86|14.78
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.56||||0.56|0.28|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.22|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.22|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.26|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.56||||0.56|0.23|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.56||||0.56|0.22|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.56||||0.56|0.28|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|0.56||||0.56|0.11|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.08|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56|0|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.56||||0.56|0.39|0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.08
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.56||||0.56|0|0.39|0.08
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1463.36||||1463.36|658.51|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1463.36||||1463.36|731.68|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1463.36||||1463.36|585.34|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1463.36||||1463.36|585.34|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1463.36||||1463.36|687.78|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1463.36||||1463.36|599.98|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1463.36||||1463.36|585.34|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1463.36||||1463.36|731.68|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1463.36||||1463.36|658.51|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1463.36||||1463.36|658.51|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|1463.36||||1463.36|292.67|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1463.36||||1463.36|204.87|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1463.36||||1463.36|0|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|1463.36||||1463.36|1009.72|1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1463.36||||1463.36||1009.72|204.87
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1463.36||||1463.36|0|1009.72|204.87
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|42.6||||42.6|19.17|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|42.6||||42.6|21.3|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.6||||42.6|17.04|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.6||||42.6|17.04|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.6||||42.6|20.02|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|42.6||||42.6|17.47|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|42.6||||42.6|17.04|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|42.6||||42.6|21.3|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.6||||42.6|19.17|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.6||||42.6|19.17|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|Self-pay|Self-pay|42.6||||42.6|8.52|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|TML [1980]|TML [198000]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.6||||42.6|5.96|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.6||||42.6|0|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|42.6||||42.6|29.39|29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.6||||42.6||29.39|5.96
1759|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|42.6||||42.6|0|29.39|5.96
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1397.88||||1397.88|698.94|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1397.88||||1397.88|559.15|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1397.88||||1397.88|559.15|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1397.88||||1397.88|657|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1397.88||||1397.88|573.13|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1397.88||||1397.88|559.15|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1397.88||||1397.88|698.94|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1397.88||||1397.88|279.58|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1397.88||||1397.88|195.7|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1397.88||||1397.88|964.54|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1397.88||||1397.88||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1397.88||||1397.88|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMBETTER [2930]|AMBETTER [293000]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2378.64||||2378.64|1189.32|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2378.64||||2378.64|951.46|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2378.64||||2378.64|951.46|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2378.64||||2378.64|1117.96|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2378.64||||2378.64|975.24|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA PPO [126025]|2378.64||||2378.64|951.46|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2378.64||||2378.64|1189.32|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|2378.64||||2378.64|475.73|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|TML [1980]|TML [198000]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2378.64||||2378.64|333.01|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UNICARE [2040]|UNICARE [204000]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WEB TPA [2115]|WEB TPA [211500]|2378.64||||2378.64|1641.26|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2378.64||||2378.64||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TML WC [212537]|2378.64||||2378.64|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|865.92||||865.92|432.96|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|865.92||||865.92|346.37|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|865.92||||865.92|346.37|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|865.92||||865.92|406.98|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|865.92||||865.92|355.03|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|865.92||||865.92|346.37|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|865.92||||865.92|432.96|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|865.92||||865.92|173.18|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|865.92||||865.92|121.23|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|865.92||||865.92|0|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|865.92||||865.92|597.48|1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|865.92||||865.92||1641.26|121.23
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|865.92||||865.92|0|1641.26|121.23
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|302.71||||302.71|136.22|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|302.71||||302.71|151.36|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|302.71||||302.71|121.08|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|302.71||||302.71|121.08|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|302.71||||302.71|142.27|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|302.71||||302.71|124.11|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|302.71||||302.71|121.08|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|302.71||||302.71|151.36|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|302.71||||302.71|136.22|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|302.71||||302.71|136.22|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|302.71||||302.71|60.54|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|302.71||||302.71|42.38|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|302.71||||302.71|0|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|302.71||||302.71|208.87|208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|302.71||||302.71||208.87|42.38
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|302.71||||302.71|0|208.87|42.38
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AARP [1000]|AARP [100000]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AETNA [1015]|AETNA [101529]|52.87||||52.87|23.79|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AMBETTER [2930]|AMBETTER [293000]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.87||||52.87|26.44|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.87||||52.87|21.15|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.87||||52.87|21.15|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.87||||52.87|24.85|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.87||||52.87|21.68|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|CIGNA [1260]|CIGNA PPO [126025]|52.87||||52.87|21.15|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|GROUP PENSION ADMIN [1450]|GPA [145000]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.87||||52.87|26.44|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.87||||52.87|23.79|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.87||||52.87|23.79|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|PHCS [1780]|PHCS MULTIPLAN [178000]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|Self-pay|Self-pay|52.87||||52.87|10.57|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|TML [1980]|TML [198000]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.87||||52.87|7.4|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|UNICARE [2040]|UNICARE [204000]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.87||||52.87|0|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|WEB TPA [2115]|WEB TPA [211500]|52.87||||52.87|36.48|36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.87||||52.87||36.48|7.4
1769|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % VAGINAL CREAM|45 g|WORKER'S COMP [2125]|TML WC [212537]|52.87||||52.87|0|36.48|7.4
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AARP [1000]|AARP [100000]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AETNA [1015]|AETNA [101529]|730.86||||730.86|328.89|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AMBETTER [2930]|AMBETTER [293000]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|730.86||||730.86|365.43|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|730.86||||730.86|292.34|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|730.86||||730.86|292.34|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|730.86||||730.86|343.5|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|730.86||||730.86|299.65|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|CIGNA [1260]|CIGNA PPO [126025]|730.86||||730.86|292.34|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|GROUP PENSION ADMIN [1450]|GPA [145000]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|730.86||||730.86|365.43|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|730.86||||730.86|328.89|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|730.86||||730.86|328.89|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|PHCS [1780]|PHCS MULTIPLAN [178000]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|Self-pay|Self-pay|730.86||||730.86|146.17|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|TML [1980]|TML [198000]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|730.86||||730.86|102.32|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|UNICARE [2040]|UNICARE [204000]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|730.86||||730.86|0|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|WEB TPA [2115]|WEB TPA [211500]|730.86||||730.86|504.29|504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|730.86||||730.86||504.29|102.32
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|18 g|WORKER'S COMP [2125]|TML WC [212537]|730.86||||730.86|0|504.29|102.32
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|191.4||||191.4|86.13|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|191.4||||191.4|95.7|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191.4||||191.4|76.56|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191.4||||191.4|76.56|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191.4||||191.4|89.96|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|191.4||||191.4|78.47|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|191.4||||191.4|76.56|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|191.4||||191.4|95.7|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191.4||||191.4|86.13|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191.4||||191.4|86.13|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|Self-pay|Self-pay|191.4||||191.4|38.28|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|TML [1980]|TML [198000]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191.4||||191.4|26.8|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191.4||||191.4|0|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|191.4||||191.4|132.07|132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191.4||||191.4||132.07|26.8
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|191.4||||191.4|0|132.07|26.8
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.59||||6.59|2.97|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.59||||6.59|3.3|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.59||||6.59|2.64|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.59||||6.59|2.64|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.59||||6.59|3.1|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.59||||6.59|2.7|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.59||||6.59|2.64|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.59||||6.59|3.3|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.59||||6.59|2.97|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.59||||6.59|2.97|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.59||||6.59|1.32|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.59||||6.59|0.92|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.59||||6.59|0|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.59||||6.59|4.55|4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.59||||6.59||4.55|0.92
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.59||||6.59|0|4.55|0.92
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AARP [1000]|AARP [100000]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|283.8||||283.8|127.71|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|283.8||||283.8|141.9|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|283.8||||283.8|113.52|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|283.8||||283.8|113.52|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|283.8||||283.8|133.39|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|283.8||||283.8|116.36|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|283.8||||283.8|113.52|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|283.8||||283.8|141.9|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|283.8||||283.8|127.71|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|283.8||||283.8|127.71|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|Self-pay|Self-pay|283.8||||283.8|56.76|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|TML [1980]|TML [198000]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|283.8||||283.8|39.73|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|283.8||||283.8|0|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|283.8||||283.8|195.82|195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|283.8||||283.8||195.82|39.73
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|283.8||||283.8|0|195.82|39.73
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.34||||11.34|5.1|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.34||||11.34|5.67|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.34||||11.34|4.54|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.34||||11.34|4.54|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.34||||11.34|5.33|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.34||||11.34|4.65|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.34||||11.34|4.54|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.34||||11.34|5.67|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.34||||11.34|5.1|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.34||||11.34|5.1|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|Self-pay|Self-pay|11.34||||11.34|2.27|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.34||||11.34|1.59|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.34||||11.34|0|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.34||||11.34|7.82|7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.34||||11.34||7.82|1.59
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.34||||11.34|0|7.82|1.59
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|122.66||||122.66|55.2|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122.66||||122.66|61.33|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122.66||||122.66|49.06|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122.66||||122.66|49.06|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122.66||||122.66|57.65|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122.66||||122.66|50.29|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|122.66||||122.66|49.06|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122.66||||122.66|61.33|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122.66||||122.66|55.2|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122.66||||122.66|55.2|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|Self-pay|Self-pay|122.66||||122.66|24.53|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|TML [1980]|TML [198000]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122.66||||122.66|17.17|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122.66||||122.66|0|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|122.66||||122.66|84.64|84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122.66||||122.66||84.64|17.17
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|122.66||||122.66|0|84.64|17.17
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.15||||12.15|5.47|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.15||||12.15|6.08|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.15||||12.15|4.86|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.15||||12.15|4.86|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.15||||12.15|5.71|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.15||||12.15|4.98|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.15||||12.15|4.86|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.15||||12.15|6.08|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.15||||12.15|5.47|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.15||||12.15|5.47|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|12.15||||12.15|2.43|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.15||||12.15|1.7|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.15||||12.15|0|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.15||||12.15|8.38|8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.15||||12.15||8.38|1.7
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.15||||12.15|0|8.38|1.7
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.7||||4.7|2.12|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.7||||4.7|2.35|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.7||||4.7|1.88|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.7||||4.7|1.88|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.7||||4.7|2.21|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.7||||4.7|1.93|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.7||||4.7|1.88|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.7||||4.7|2.35|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.7||||4.7|2.12|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.7||||4.7|2.12|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|4.7||||4.7|0.94|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.7||||4.7|0.66|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.7||||4.7|0|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.7||||4.7|3.24|3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.7||||4.7||3.24|0.66
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.7||||4.7|0|3.24|0.66
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|229.42||||229.42|103.24|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|229.42||||229.42|65.04|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|229.42||||229.42|114.71|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|229.42||||229.42|91.77|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|229.42||||229.42|91.77|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|229.42||||229.42|107.83|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|229.42||||229.42|94.06|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|229.42||||229.42|91.77|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|229.42||||229.42|114.71|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|229.42||||229.42|103.24|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|229.42||||229.42|103.24|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|229.42||||229.42|45.88|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|TML [1980]|TML [198000]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|229.42||||229.42|32.12|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|229.42||||229.42|0|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|229.42||||229.42|158.3|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|229.42||||229.42|61.94|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|229.42||||229.42|123.89|158.3|32.12
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|229.42||||229.42|0|158.3|32.12
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AARP [1000]|AARP [100000]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AETNA [1015]|AETNA [101529]|203.89||||203.89|91.75|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMBETTER [2930]|AMBETTER [293000]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203.89||||203.89|101.95|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203.89||||203.89|81.56|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203.89||||203.89|81.56|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203.89||||203.89|95.83|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203.89||||203.89|83.59|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA [1260]|CIGNA PPO [126025]|203.89||||203.89|81.56|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203.89||||203.89|101.95|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203.89||||203.89|91.75|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203.89||||203.89|91.75|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|Self-pay|Self-pay|203.89||||203.89|40.78|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|TML [1980]|TML [198000]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203.89||||203.89|28.54|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNICARE [2040]|UNICARE [204000]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203.89||||203.89|0|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WEB TPA [2115]|WEB TPA [211500]|203.89||||203.89|140.68|140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203.89||||203.89||140.68|28.54
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WORKER'S COMP [2125]|TML WC [212537]|203.89||||203.89|0|140.68|28.54
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AARP [1000]|AARP [100000]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AETNA [1015]|AETNA [101529]|116.16||||116.16|52.27|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMBETTER [2930]|AMBETTER [293000]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|116.16||||116.16|58.08|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.16||||116.16|46.46|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.16||||116.16|46.46|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.16||||116.16|54.6|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|116.16||||116.16|47.63|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA [1260]|CIGNA PPO [126025]|116.16||||116.16|46.46|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|GROUP PENSION ADMIN [1450]|GPA [145000]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|116.16||||116.16|58.08|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.16||||116.16|52.27|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.16||||116.16|52.27|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|PHCS [1780]|PHCS MULTIPLAN [178000]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|Self-pay|Self-pay|116.16||||116.16|23.23|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|TML [1980]|TML [198000]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.16||||116.16|16.26|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UNICARE [2040]|UNICARE [204000]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.16||||116.16|0|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WEB TPA [2115]|WEB TPA [211500]|116.16||||116.16|80.15|80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.16||||116.16||80.15|16.26
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WORKER'S COMP [2125]|TML WC [212537]|116.16||||116.16|0|80.15|16.26
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AARP [1000]|AARP [100000]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AETNA [1015]|AETNA [101529]|72.6||||72.6|32.67|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMBETTER [2930]|AMBETTER [293000]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72.6||||72.6|36.3|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72.6||||72.6|29.04|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72.6||||72.6|29.04|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72.6||||72.6|34.12|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|72.6||||72.6|29.77|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA [1260]|CIGNA PPO [126025]|72.6||||72.6|29.04|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|GROUP PENSION ADMIN [1450]|GPA [145000]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72.6||||72.6|36.3|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72.6||||72.6|32.67|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72.6||||72.6|32.67|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|PHCS [1780]|PHCS MULTIPLAN [178000]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|Self-pay|Self-pay|72.6||||72.6|14.52|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|TML [1980]|TML [198000]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72.6||||72.6|10.16|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNICARE [2040]|UNICARE [204000]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72.6||||72.6|0|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WEB TPA [2115]|WEB TPA [211500]|72.6||||72.6|50.09|50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72.6||||72.6||50.09|10.16
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WORKER'S COMP [2125]|TML WC [212537]|72.6||||72.6|0|50.09|10.16
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.28||||2.28|1.03|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.28||||2.28|1.14|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.28||||2.28|0.91|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.28||||2.28|0.91|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.28||||2.28|1.07|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.28||||2.28|0.93|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.28||||2.28|0.91|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.28||||2.28|1.14|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.28||||2.28|1.03|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.28||||2.28|1.03|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.28||||2.28|0.46|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.28||||2.28|0.32|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.28||||2.28|0|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.28||||2.28|1.57|1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.28||||2.28||1.57|0.32
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.28||||2.28|0|1.57|0.32
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AARP [1000]|AARP [100000]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AETNA [1015]|AETNA [101529]|491.7||||491.7|221.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|491.7||||491.7|245.85|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|491.7||||491.7|196.68|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|491.7||||491.7|196.68|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|491.7||||491.7|231.1|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|491.7||||491.7|201.6|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA [1260]|CIGNA PPO [126025]|491.7||||491.7|196.68|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|491.7||||491.7|245.85|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|491.7||||491.7|221.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|491.7||||491.7|221.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|Self-pay|Self-pay|491.7||||491.7|98.34|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|TML [1980]|TML [198000]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|491.7||||491.7|68.84|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UNICARE [2040]|UNICARE [204000]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|491.7||||491.7|0|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|491.7||||491.7|339.27|339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|491.7||||491.7||339.27|68.84
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WORKER'S COMP [2125]|TML WC [212537]|491.7||||491.7|0|339.27|68.84
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.97||||2.97|1.34|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.97||||2.97|1.49|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.97||||2.97|1.19|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.97||||2.97|1.19|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.97||||2.97|1.4|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.97||||2.97|1.22|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.97||||2.97|1.19|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.97||||2.97|1.49|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.97||||2.97|1.34|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.97||||2.97|1.34|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|Self-pay|Self-pay|2.97||||2.97|0.59|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TML [1980]|TML [198000]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.97||||2.97|0.42|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.97||||2.97|0|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.97||||2.97|2.05|2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.97||||2.97||2.05|0.42
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.97||||2.97|0|2.05|0.42
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AARP [1000]|AARP [100000]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|8.08||||8.08|3.64|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.08||||8.08|4.04|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.08||||8.08|3.23|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.08||||8.08|3.23|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.08||||8.08|3.8|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.08||||8.08|3.31|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.08||||8.08|3.23|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.08||||8.08|4.04|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.08||||8.08|3.64|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.08||||8.08|3.64|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|Self-pay|Self-pay|8.08||||8.08|1.62|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TML [1980]|TML [198000]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.08||||8.08|1.13|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.08||||8.08|0|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.08||||8.08|5.58|5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.08||||8.08||5.58|1.13
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.08||||8.08|0|5.58|1.13
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.1||||1.1|0.5|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.1||||1.1|0.55|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.1||||1.1|0.44|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.1||||1.1|0.44|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.1||||1.1|0.52|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.1||||1.1|0.45|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.1||||1.1|0.44|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.1||||1.1|0.55|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.1||||1.1|0.5|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.1||||1.1|0.5|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|Self-pay|Self-pay|1.1||||1.1|0.22|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.1||||1.1|0.15|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.1||||1.1|0|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.1||||1.1|0.76|0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.1||||1.1||0.76|0.15
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.1||||1.1|0|0.76|0.15
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AARP [1000]|AARP [100000]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AETNA [1015]|AETNA [101529]|141.24||||141.24|63.56|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|141.24||||141.24|70.62|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141.24||||141.24|56.5|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141.24||||141.24|56.5|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141.24||||141.24|66.38|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|141.24||||141.24|57.91|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|141.24||||141.24|56.5|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|141.24||||141.24|70.62|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141.24||||141.24|63.56|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141.24||||141.24|63.56|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|Self-pay|Self-pay|141.24||||141.24|28.25|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|TML [1980]|TML [198000]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141.24||||141.24|19.77|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNICARE [2040]|UNICARE [204000]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141.24||||141.24|0|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|141.24||||141.24|97.46|97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|141.24||||141.24||97.46|19.77
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|141.24||||141.24|0|97.46|19.77
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.79||||1.79|0.81|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.79||||1.79|0.9|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.79||||1.79|0.72|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.79||||1.79|0.72|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.79||||1.79|0.84|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.79||||1.79|0.73|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.79||||1.79|0.72|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.79||||1.79|0.9|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.79||||1.79|0.81|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.79||||1.79|0.81|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.79||||1.79|0.36|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.79||||1.79|0.25|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.79||||1.79|0|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.79||||1.79|1.24|1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.79||||1.79||1.24|0.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.79||||1.79|0|1.24|0.25
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.91||||2.91|1.31|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.91||||2.91|1.46|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.91||||2.91|1.16|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.91||||2.91|1.16|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.91||||2.91|1.37|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.91||||2.91|1.19|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.91||||2.91|1.16|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.91||||2.91|1.46|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.91||||2.91|1.31|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.91||||2.91|1.31|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|2.91||||2.91|0.58|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.91||||2.91|0.41|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.91||||2.91|0|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.91||||2.91|2.01|2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.91||||2.91||2.01|0.41
18918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.91||||2.91|0|2.01|0.41
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.21||||3.21|1.44|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.21||||3.21|1.61|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.21||||3.21|1.28|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.21||||3.21|1.28|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.21||||3.21|1.51|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.21||||3.21|1.32|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.21||||3.21|1.28|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.21||||3.21|1.61|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.21||||3.21|1.44|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.21||||3.21|1.44|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|3.21||||3.21|0.64|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.21||||3.21|0.45|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.21||||3.21|0|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.21||||3.21|2.21|2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.21||||3.21||2.21|0.45
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.21||||3.21|0|2.21|0.45
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.94||||3.94|1.77|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.94||||3.94|1.97|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.94||||3.94|1.58|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.94||||3.94|1.58|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.94||||3.94|1.85|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.94||||3.94|1.62|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.94||||3.94|1.58|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.94||||3.94|1.97|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.94||||3.94|1.77|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.94||||3.94|1.77|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.94||||3.94|0.79|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.94||||3.94|0.55|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.94||||3.94|0|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.94||||3.94|2.72|2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.94||||3.94||2.72|0.55
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.94||||3.94|0|2.72|0.55
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.27||||6.27|2.82|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.27||||6.27|3.14|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.27||||6.27|2.51|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.27||||6.27|2.51|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.27||||6.27|2.95|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.27||||6.27|2.57|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.27||||6.27|2.51|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.27||||6.27|3.14|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.27||||6.27|2.82|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.27||||6.27|2.82|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|6.27||||6.27|1.25|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.27||||6.27|0.88|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.27||||6.27|0|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.27||||6.27|4.33|4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.27||||6.27||4.33|0.88
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.27||||6.27|0|4.33|0.88
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.06||||1.06|0.48|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.06||||1.06|0.53|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.06||||1.06|0.42|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.42|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.06||||1.06|0.5|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.06||||1.06|0.43|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.06||||1.06|0.42|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.06||||1.06|0.53|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0.48|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0.48|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.06||||1.06|0.21|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.06||||1.06|0.15|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06|0|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.06||||1.06|0.73|0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.06||||1.06||0.73|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.06||||1.06|0|0.73|0.15
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.89||||4.89|2.2|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.89||||4.89|2.45|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.89||||4.89|1.96|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.89||||4.89|1.96|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.89||||4.89|2.3|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.89||||4.89|2|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.89||||4.89|1.96|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.89||||4.89|2.45|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.89||||4.89|2.2|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.89||||4.89|2.2|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|4.89||||4.89|0.98|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.89||||4.89|0.68|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.89||||4.89|0|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.89||||4.89|3.37|3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.89||||4.89||3.37|0.68
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.89||||4.89|0|3.37|0.68
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.67|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.38|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.38|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|2.79|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|2.44|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.67|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.67|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|Self-pay|Self-pay|5.94||||5.94|1.19|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|0.83|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94|0|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|0.83
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.67|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.38|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.38|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|2.79|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|2.44|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.67|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.67|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|5.94||||5.94|1.19|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|0.83|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94|0|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|0.83
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94|0|4.1|0.83
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|521.93||||521.93|234.87|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|521.93||||521.93|260.97|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|521.93||||521.93|208.77|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|521.93||||521.93|208.77|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|521.93||||521.93|245.31|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|521.93||||521.93|213.99|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|521.93||||521.93|208.77|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|521.93||||521.93|260.97|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|521.93||||521.93|234.87|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|521.93||||521.93|234.87|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|521.93||||521.93|104.39|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|521.93||||521.93|73.07|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|521.93||||521.93|0|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|521.93||||521.93|360.13|360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|521.93||||521.93||360.13|73.07
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|521.93||||521.93|0|360.13|73.07
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AARP [1000]|AARP [100000]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AETNA [1015]|AETNA [101529]|0.9||||0.9|0.41|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AMBETTER [2930]|AMBETTER [293000]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.9||||0.9|0.45|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.9||||0.9|0.36|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.9||||0.9|0.36|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.9||||0.9|0.42|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.9||||0.9|0.37|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|CIGNA [1260]|CIGNA PPO [126025]|0.9||||0.9|0.36|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.9||||0.9|0.45|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.9||||0.9|0.41|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.9||||0.9|0.41|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|Self-pay|Self-pay|0.9||||0.9|0.18|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|TML [1980]|TML [198000]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.9||||0.9|0.13|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|UNICARE [2040]|UNICARE [204000]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.9||||0.9|0|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|WEB TPA [2115]|WEB TPA [211500]|0.9||||0.9|0.62|0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.9||||0.9||0.62|0.13
19677|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % TOPICAL AEROSOL|1 g|WORKER'S COMP [2125]|TML WC [212537]|0.9||||0.9|0|0.62|0.13
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|369.6||||369.6|166.32|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|369.6||||369.6|184.8|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|369.6||||369.6|147.84|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|369.6||||369.6|147.84|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|369.6||||369.6|173.71|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|369.6||||369.6|151.54|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|369.6||||369.6|147.84|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|369.6||||369.6|184.8|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|369.6||||369.6|166.32|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|369.6||||369.6|166.32|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|369.6||||369.6|73.92|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|TML [1980]|TML [198000]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|369.6||||369.6|51.74|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|369.6||||369.6|0|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|369.6||||369.6|255.02|255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|369.6||||369.6||255.02|51.74
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|369.6||||369.6|0|255.02|51.74
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AARP [1000]|AARP [100000]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AETNA [1015]|AETNA [101529]|1818.24||||1818.24|818.21|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMBETTER [2930]|AMBETTER [293000]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1818.24||||1818.24|909.12|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1818.24||||1818.24|727.3|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1818.24||||1818.24|727.3|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1818.24||||1818.24|854.57|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1818.24||||1818.24|745.48|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA [1260]|CIGNA PPO [126025]|1818.24||||1818.24|727.3|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1818.24||||1818.24|909.12|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1818.24||||1818.24|818.21|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1818.24||||1818.24|818.21|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|Self-pay|Self-pay|1818.24||||1818.24|363.65|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|TML [1980]|TML [198000]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1818.24||||1818.24|254.55|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UNICARE [2040]|UNICARE [204000]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1818.24||||1818.24|0|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WEB TPA [2115]|WEB TPA [211500]|1818.24||||1818.24|1254.59|1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1818.24||||1818.24||1254.59|254.55
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WORKER'S COMP [2125]|TML WC [212537]|1818.24||||1818.24|0|1254.59|254.55
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|221.1||||221.1|99.5|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|221.1||||221.1|110.55|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221.1||||221.1|88.44|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221.1||||221.1|88.44|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221.1||||221.1|103.92|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|221.1||||221.1|90.65|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|221.1||||221.1|88.44|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|221.1||||221.1|110.55|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221.1||||221.1|99.5|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221.1||||221.1|99.5|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|221.1||||221.1|44.22|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221.1||||221.1|30.95|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221.1||||221.1|0|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|221.1||||221.1|152.56|152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221.1||||221.1||152.56|30.95
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|221.1||||221.1|0|152.56|30.95
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|9.13||||9.13|4.11|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.13||||9.13|4.57|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.13||||9.13|3.65|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.13||||9.13|3.65|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.13||||9.13|4.29|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.13||||9.13|3.74|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|9.13||||9.13|3.65|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.13||||9.13|4.57|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.13||||9.13|4.11|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.13||||9.13|4.11|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|9.13||||9.13|1.83|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.13||||9.13|1.28|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.13||||9.13|0|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|9.13||||9.13|6.3|6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.13||||9.13||6.3|1.28
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|9.13||||9.13|0|6.3|1.28
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.98|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.17||||2.17|1.09|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|0.87|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|0.87|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.02|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.17||||2.17|0.89|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.17||||2.17|0.87|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.17||||2.17|1.09|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.98|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.98|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|Self-pay|Self-pay|2.17||||2.17|0.43|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|TML [1980]|TML [198000]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.3|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17|0|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.17||||2.17|1.5|1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.3
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.17||||2.17|0|1.5|0.3
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AARP [1000]|AARP [100000]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA [1015]|AETNA [101529]|363.66||||363.66|163.65|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMBETTER [2930]|AMBETTER [293000]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|363.66||||363.66|181.83|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363.66||||363.66|145.46|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363.66||||363.66|145.46|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363.66||||363.66|170.92|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|363.66||||363.66|149.1|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA PPO [126025]|363.66||||363.66|145.46|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|363.66||||363.66|181.83|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363.66||||363.66|163.65|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363.66||||363.66|163.65|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|Self-pay|Self-pay|363.66||||363.66|72.73|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|TML [1980]|TML [198000]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363.66||||363.66|50.91|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNICARE [2040]|UNICARE [204000]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363.66||||363.66|0|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WEB TPA [2115]|WEB TPA [211500]|363.66||||363.66|250.93|250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363.66||||363.66||250.93|50.91
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TML WC [212537]|363.66||||363.66|0|250.93|50.91
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.19||||1.19|0.54|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.19||||1.19|0.6|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.19||||1.19|0.48|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.19||||1.19|0.48|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.19||||1.19|0.56|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.19||||1.19|0.49|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.19||||1.19|0.48|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.19||||1.19|0.6|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.19||||1.19|0.54|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.19||||1.19|0.54|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|1.19||||1.19|0.24|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.19||||1.19|0.17|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.19||||1.19|0|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.19||||1.19|0.82|0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.19||||1.19||0.82|0.17
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.19||||1.19|0|0.82|0.17
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.18||||2.18|0.98|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.18||||2.18|1.09|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.18||||2.18|0.87|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.18||||2.18|0.87|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.18||||2.18|1.02|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.18||||2.18|0.89|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.18||||2.18|0.87|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.18||||2.18|1.09|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.18||||2.18|0.98|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.18||||2.18|0.98|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.18||||2.18|0.44|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.18||||2.18|0.31|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.18||||2.18|0|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.18||||2.18|1.5|1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.18||||2.18||1.5|0.31
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.18||||2.18|0|1.5|0.31
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|228.17||||228.17|102.68|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|228.17||||228.17|114.09|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|228.17||||228.17|91.27|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|228.17||||228.17|91.27|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|228.17||||228.17|107.24|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|228.17||||228.17|93.55|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|228.17||||228.17|91.27|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|228.17||||228.17|114.09|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|228.17||||228.17|102.68|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|228.17||||228.17|102.68|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|228.17||||228.17|45.63|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|228.17||||228.17|31.94|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|228.17||||228.17|0|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|228.17||||228.17|157.44|157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|228.17||||228.17||157.44|31.94
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|228.17||||228.17|0|157.44|31.94
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.8||||19.8|8.91|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.8||||19.8|9.9|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.8||||19.8|7.92|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.8||||19.8|7.92|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.8||||19.8|9.31|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.8||||19.8|8.12|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.8||||19.8|7.92|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.8||||19.8|9.9|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.8||||19.8|8.91|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.8||||19.8|8.91|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|19.8||||19.8|3.96|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.8||||19.8|2.77|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.8||||19.8|0|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.8||||19.8|13.66|13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.8||||19.8||13.66|2.77
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.8||||19.8|0|13.66|2.77
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.81||||5.81|2.61|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.81||||5.81|2.91|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.81||||5.81|2.32|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.81||||5.81|2.32|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.81||||5.81|2.73|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.81||||5.81|2.38|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.81||||5.81|2.32|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.81||||5.81|2.91|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.81||||5.81|2.61|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.81||||5.81|2.61|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|5.81||||5.81|1.16|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.81||||5.81|0.81|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.81||||5.81|0|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.81||||5.81|4.01|4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.81||||5.81||4.01|0.81
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.81||||5.81|0|4.01|0.81
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.66||||11.66|5.25|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.66||||11.66|5.83|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.66||||11.66|4.66|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.66||||11.66|4.66|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.66||||11.66|5.48|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.66||||11.66|4.78|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.66||||11.66|4.66|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.66||||11.66|5.83|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.66||||11.66|5.25|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.66||||11.66|5.25|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|Self-pay|Self-pay|11.66||||11.66|2.33|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.66||||11.66|1.63|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.66||||11.66|0|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.66||||11.66|8.05|8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.66||||11.66||8.05|1.63
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.66||||11.66|0|8.05|1.63
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.46||||1.46|0.66|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.46||||1.46|0.73|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.46||||1.46|0.58|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.46||||1.46|0.58|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.46||||1.46|0.69|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.46||||1.46|0.6|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.46||||1.46|0.58|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.46||||1.46|0.73|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.46||||1.46|0.66|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.46||||1.46|0.66|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.46||||1.46|0.29|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.46||||1.46|0.2|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.46||||1.46|0|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.46||||1.46|1.01|1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.46||||1.46||1.01|0.2
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.46||||1.46|0|1.01|0.2
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|62.04||||62.04|27.92|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62.04||||62.04|31.02|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.04||||62.04|24.82|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.04||||62.04|24.82|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.04||||62.04|29.16|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62.04||||62.04|25.44|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|62.04||||62.04|24.82|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62.04||||62.04|31.02|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.04||||62.04|27.92|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.04||||62.04|27.92|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|62.04||||62.04|12.41|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.04||||62.04|8.69|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.04||||62.04|0|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|62.04||||62.04|42.81|42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62.04||||62.04||42.81|8.69
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|62.04||||62.04|0|42.81|8.69
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AARP [1000]|AARP [100000]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AETNA [1015]|AETNA [101529]|181.07||||181.07|81.48|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMBETTER [2930]|AMBETTER [293000]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.07||||181.07|90.54|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.07||||181.07|72.43|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.07||||181.07|72.43|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.07||||181.07|85.1|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.07||||181.07|74.24|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA [1260]|CIGNA PPO [126025]|181.07||||181.07|72.43|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.07||||181.07|90.54|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.07||||181.07|81.48|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.07||||181.07|81.48|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|Self-pay|Self-pay|181.07||||181.07|36.21|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|TML [1980]|TML [198000]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.07||||181.07|25.35|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNICARE [2040]|UNICARE [204000]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.07||||181.07|0|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WEB TPA [2115]|WEB TPA [211500]|181.07||||181.07|124.94|124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.07||||181.07||124.94|25.35
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WORKER'S COMP [2125]|TML WC [212537]|181.07||||181.07|0|124.94|25.35
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AARP [1000]|AARP [100000]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AETNA [1015]|AETNA [101529]|1625.32||||1625.32|731.39|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMBETTER [2930]|AMBETTER [293000]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1625.32||||1625.32|812.66|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1625.32||||1625.32|650.13|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1625.32||||1625.32|650.13|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1625.32||||1625.32|763.9|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1625.32||||1625.32|666.38|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1625.32||||1625.32|650.13|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1625.32||||1625.32|812.66|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1625.32||||1625.32|731.39|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1625.32||||1625.32|731.39|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|Self-pay|Self-pay|1625.32||||1625.32|325.06|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|TML [1980]|TML [198000]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1625.32||||1625.32|227.54|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UNICARE [2040]|UNICARE [204000]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1625.32||||1625.32|0|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WEB TPA [2115]|WEB TPA [211500]|1625.32||||1625.32|1121.47|1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1625.32||||1625.32||1121.47|227.54
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1625.32||||1625.32|0|1121.47|227.54
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0.66|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.47||||1.47|0.74|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|0.59|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.59|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.69|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.47||||1.47|0.6|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.47||||1.47|0.59|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.47||||1.47|0.74|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0.66|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0.66|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.29|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.21|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47|0|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.47||||1.47|1.01|1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.47||||1.47||1.01|0.21
21288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.47||||1.47|0|1.01|0.21
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.95||||1.95|0.88|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.95||||1.95|0.98|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.95||||1.95|0.78|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.95||||1.95|0.78|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.95||||1.95|0.92|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.95||||1.95|0.8|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.95||||1.95|0.78|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.95||||1.95|0.98|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.95||||1.95|0.88|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.95||||1.95|0.88|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|1.95||||1.95|0.39|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.95||||1.95|0.27|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.95||||1.95|0|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.95||||1.95|1.35|1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.95||||1.95||1.35|0.27
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.95||||1.95|0|1.35|0.27
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.33||||3.33|1.5|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.33||||3.33|1.67|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.33||||3.33|1.33|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.33||||3.33|1.33|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.33||||3.33|1.57|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.33||||3.33|1.37|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.33||||3.33|1.33|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.33||||3.33|1.67|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.33||||3.33|1.5|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.33||||3.33|1.5|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|3.33||||3.33|0.67|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.33||||3.33|0.47|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.33||||3.33|0|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.33||||3.33|2.3|2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.33||||3.33||2.3|0.47
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.33||||3.33|0|2.3|0.47
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|26.04||||26.04|11.72|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.04||||26.04|13.02|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.04||||26.04|10.42|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.04||||26.04|10.42|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.04||||26.04|12.24|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.04||||26.04|10.68|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|26.04||||26.04|10.42|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.04||||26.04|13.02|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.04||||26.04|11.72|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.04||||26.04|11.72|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|26.04||||26.04|5.21|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.04||||26.04|3.65|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.04||||26.04|0|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|26.04||||26.04|17.97|17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.04||||26.04||17.97|3.65
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|26.04||||26.04|0|17.97|3.65
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.13||||11.13|5.01|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.13||||11.13|5.57|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.13||||11.13|4.45|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.13||||11.13|4.45|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.13||||11.13|5.23|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.13||||11.13|4.56|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.13||||11.13|4.45|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.13||||11.13|5.57|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.13||||11.13|5.01|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.13||||11.13|5.01|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|11.13||||11.13|2.23|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.13||||11.13|1.56|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.13||||11.13|0|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.13||||11.13|7.68|7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.13||||11.13||7.68|1.56
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.13||||11.13|0|7.68|1.56
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.5||||6.5|2.93|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.5||||6.5|3.25|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.5||||6.5|2.6|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.5||||6.5|2.6|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.5||||6.5|3.06|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.5||||6.5|2.67|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.5||||6.5|2.6|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.5||||6.5|3.25|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.5||||6.5|2.93|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.5||||6.5|2.93|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|6.5||||6.5|1.3|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.5||||6.5|0.91|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.5||||6.5|0|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.5||||6.5|4.49|4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.5||||6.5||4.49|0.91
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.5||||6.5|0|4.49|0.91
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.49||||7.49|3.37|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.49||||7.49|3.75|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.49||||7.49|3|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.49||||7.49|3|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.49||||7.49|3.52|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.49||||7.49|3.07|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.49||||7.49|3|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.49||||7.49|3.75|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.49||||7.49|3.37|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.49||||7.49|3.37|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|7.49||||7.49|1.5|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.49||||7.49|1.05|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.49||||7.49|0|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.49||||7.49|5.17|5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.49||||7.49||5.17|1.05
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.49||||7.49|0|5.17|1.05
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.29||||4.29|1.93|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.29||||4.29|2.15|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.29||||4.29|1.72|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.29||||4.29|1.72|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.29||||4.29|2.02|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.29||||4.29|1.76|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.29||||4.29|1.72|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.29||||4.29|2.15|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.29||||4.29|1.93|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.29||||4.29|1.93|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|4.29||||4.29|0.86|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.29||||4.29|0.6|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.29||||4.29|0|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.29||||4.29|2.96|2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.29||||4.29||2.96|0.6
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.29||||4.29|0|2.96|0.6
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7||||7|3.15|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7||||7|3.5|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7||||7|2.8|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7||||7|2.8|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7||||7|3.29|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7||||7|2.87|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7||||7|2.8|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7||||7|3.5|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7||||7|3.15|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7||||7|3.15|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|7||||7|1.4|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7||||7|0.98|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7||||7|0|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7||||7|4.83|4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7||||7||4.83|0.98
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7||||7|0|4.83|0.98
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AARP [1000]|AARP [100000]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AETNA [1015]|AETNA [101529]|3528.23||||3528.23|1587.7|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMBETTER [2930]|AMBETTER [293000]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3528.23||||3528.23|1764.12|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3528.23||||3528.23|1411.29|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3528.23||||3528.23|1411.29|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3528.23||||3528.23|1658.27|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3528.23||||3528.23|1446.57|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|3528.23||||3528.23|1411.29|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3528.23||||3528.23|1764.12|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3528.23||||3528.23|1587.7|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3528.23||||3528.23|1587.7|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|Self-pay|Self-pay|3528.23||||3528.23|705.65|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|TML [1980]|TML [198000]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3528.23||||3528.23|493.95|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNICARE [2040]|UNICARE [204000]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3528.23||||3528.23|0|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WEB TPA [2115]|WEB TPA [211500]|3528.23||||3528.23|2434.48|2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3528.23||||3528.23||2434.48|493.95
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|3528.23||||3528.23|0|2434.48|493.95
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.42||||3.42|1.54|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.42||||3.42|1.71|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.42||||3.42|1.37|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.42||||3.42|1.37|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.42||||3.42|1.61|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.42||||3.42|1.4|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.42||||3.42|1.37|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.42||||3.42|1.71|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.42||||3.42|1.54|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.42||||3.42|1.54|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|Self-pay|Self-pay|3.42||||3.42|0.68|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.42||||3.42|0.48|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.42||||3.42|0|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.42||||3.42|2.36|2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.42||||3.42||2.36|0.48
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.42||||3.42|0|2.36|0.48
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|75.27||||75.27|33.87|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.27||||75.27|37.64|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.27||||75.27|30.11|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.27||||75.27|30.11|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.27||||75.27|35.38|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.27||||75.27|30.86|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|75.27||||75.27|30.11|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.27||||75.27|37.64|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.27||||75.27|33.87|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.27||||75.27|33.87|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|Self-pay|Self-pay|75.27||||75.27|15.05|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|TML [1980]|TML [198000]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.27||||75.27|10.54|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.27||||75.27|0|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|75.27||||75.27|51.94|51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.27||||75.27||51.94|10.54
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|75.27||||75.27|0|51.94|10.54
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AARP [1000]|AARP [100000]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AETNA [1015]|AETNA [101529]|223.94||||223.94|100.77|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|223.94||||223.94|111.97|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223.94||||223.94|89.58|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223.94||||223.94|89.58|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223.94||||223.94|105.25|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|223.94||||223.94|91.82|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|223.94||||223.94|89.58|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|223.94||||223.94|111.97|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223.94||||223.94|100.77|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223.94||||223.94|100.77|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|Self-pay|Self-pay|223.94||||223.94|44.79|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|TML [1980]|TML [198000]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223.94||||223.94|31.35|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223.94||||223.94|0|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|223.94||||223.94|154.52|154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223.94||||223.94||154.52|31.35
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|223.94||||223.94|0|154.52|31.35
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|50.64||||50.64|22.79|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.64||||50.64|25.32|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.64||||50.64|20.26|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.64||||50.64|20.26|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.64||||50.64|23.8|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50.64||||50.64|20.76|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|50.64||||50.64|20.26|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.64||||50.64|25.32|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.64||||50.64|22.79|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.64||||50.64|22.79|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|50.64||||50.64|10.13|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.64||||50.64|7.09|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.64||||50.64|0|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|50.64||||50.64|34.94|34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.64||||50.64||34.94|7.09
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|50.64||||50.64|0|34.94|7.09
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|23.76||||23.76|10.69|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.76||||23.76|11.88|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.76||||23.76|9.5|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.76||||23.76|9.5|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.76||||23.76|11.17|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.76||||23.76|9.74|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|23.76||||23.76|9.5|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.76||||23.76|11.88|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.76||||23.76|10.69|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.76||||23.76|10.69|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|23.76||||23.76|4.75|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.76||||23.76|3.33|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.76||||23.76|0|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|23.76||||23.76|16.39|16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.76||||23.76||16.39|3.33
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|23.76||||23.76|0|16.39|3.33
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|10.45||||10.45|4.7|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.45||||10.45|5.23|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.45||||10.45|4.18|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.45||||10.45|4.18|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.45||||10.45|4.91|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.45||||10.45|4.28|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|10.45||||10.45|4.18|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.45||||10.45|5.23|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.45||||10.45|4.7|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.45||||10.45|4.7|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|10.45||||10.45|2.09|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.45||||10.45|1.46|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.45||||10.45|0|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|10.45||||10.45|7.21|7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.45||||10.45||7.21|1.46
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|10.45||||10.45|0|7.21|1.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.6||||6.6|2.97|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.6||||6.6|3.3|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.6||||6.6|2.64|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.6||||6.6|2.64|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.6||||6.6|3.1|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.6||||6.6|2.71|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.6||||6.6|2.64|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.6||||6.6|3.3|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.6||||6.6|2.97|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.6||||6.6|2.97|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|Self-pay|Self-pay|6.6||||6.6|1.32|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.6||||6.6|0.92|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.6||||6.6|0|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.6||||6.6|4.55|4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.6||||6.6||4.55|0.92
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.6||||6.6|0|4.55|0.92
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AARP [1000]|AARP [100000]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AETNA [1015]|AETNA [101529]|100.85||||100.85|45.38|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AMBETTER [2930]|AMBETTER [293000]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|100.85||||100.85|50.43|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|100.85||||100.85|40.34|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|100.85||||100.85|40.34|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|100.85||||100.85|47.4|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|100.85||||100.85|41.35|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA [1260]|CIGNA PPO [126025]|100.85||||100.85|40.34|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|100.85||||100.85|50.43|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|100.85||||100.85|45.38|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|100.85||||100.85|45.38|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|Self-pay|Self-pay|100.85||||100.85|20.17|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|TML [1980]|TML [198000]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|100.85||||100.85|14.12|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UNICARE [2040]|UNICARE [204000]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|100.85||||100.85|0|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WEB TPA [2115]|WEB TPA [211500]|100.85||||100.85|69.59|69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|100.85||||100.85||69.59|14.12
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WORKER'S COMP [2125]|TML WC [212537]|100.85||||100.85|0|69.59|14.12
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|28.33||||28.33|12.75|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.33||||28.33|14.17|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.33||||28.33|11.33|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.33||||28.33|11.33|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.33||||28.33|13.32|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28.33||||28.33|11.62|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|28.33||||28.33|11.33|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.33||||28.33|14.17|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.33||||28.33|12.75|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.33||||28.33|12.75|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|Self-pay|Self-pay|28.33||||28.33|5.67|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.33||||28.33|3.97|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.33||||28.33|0|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|28.33||||28.33|19.55|19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.33||||28.33||19.55|3.97
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|28.33||||28.33|0|19.55|3.97
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AARP [1000]|AARP [100000]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AETNA [1015]|AETNA [101529]|93.78||||93.78|42.2|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AMBETTER [2930]|AMBETTER [293000]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93.78||||93.78|46.89|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93.78||||93.78|37.51|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93.78||||93.78|37.51|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93.78||||93.78|44.08|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93.78||||93.78|38.45|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|CIGNA [1260]|CIGNA PPO [126025]|93.78||||93.78|37.51|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93.78||||93.78|46.89|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93.78||||93.78|42.2|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93.78||||93.78|42.2|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|Self-pay|Self-pay|93.78||||93.78|18.76|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|TML [1980]|TML [198000]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93.78||||93.78|13.13|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|UNICARE [2040]|UNICARE [204000]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93.78||||93.78|0|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|WEB TPA [2115]|WEB TPA [211500]|93.78||||93.78|64.71|64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93.78||||93.78||64.71|13.13
23063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION|222 mL|WORKER'S COMP [2125]|TML WC [212537]|93.78||||93.78|0|64.71|13.13
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|148.5||||148.5|66.83|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|148.5||||148.5|74.25|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|148.5||||148.5|59.4|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|148.5||||148.5|59.4|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|148.5||||148.5|69.8|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|148.5||||148.5|60.89|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|148.5||||148.5|59.4|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|148.5||||148.5|74.25|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|148.5||||148.5|66.83|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|148.5||||148.5|66.83|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|148.5||||148.5|29.7|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|148.5||||148.5|20.79|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|148.5||||148.5|0|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|148.5||||148.5|102.47|102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|148.5||||148.5||102.47|20.79
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|148.5||||148.5|0|102.47|20.79
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AARP [1000]|AARP [100000]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AETNA [1015]|AETNA [101529]|672.61||||672.61|302.67|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AMBETTER [2930]|AMBETTER [293000]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|672.61||||672.61|336.31|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|672.61||||672.61|269.04|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|672.61||||672.61|269.04|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|672.61||||672.61|316.13|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|672.61||||672.61|275.77|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|CIGNA [1260]|CIGNA PPO [126025]|672.61||||672.61|269.04|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|672.61||||672.61|336.31|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|672.61||||672.61|302.67|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|672.61||||672.61|302.67|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|Self-pay|Self-pay|672.61||||672.61|134.52|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|TML [1980]|TML [198000]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|672.61||||672.61|94.17|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|UNICARE [2040]|UNICARE [204000]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|672.61||||672.61|0|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|WEB TPA [2115]|WEB TPA [211500]|672.61||||672.61|464.1|464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|672.61||||672.61||464.1|94.17
2319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR|237 mL|WORKER'S COMP [2125]|TML WC [212537]|672.61||||672.61|0|464.1|94.17
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.92||||2.92|1.31|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.92||||2.92|1.46|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.92||||2.92|1.17|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.92||||2.92|1.17|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.92||||2.92|1.37|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.92||||2.92|1.2|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.92||||2.92|1.17|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.92||||2.92|1.46|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.92||||2.92|1.31|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.92||||2.92|1.31|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|Self-pay|Self-pay|2.92||||2.92|0.58|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.92||||2.92|0.41|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.92||||2.92|0|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.92||||2.92|2.01|2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.92||||2.92||2.01|0.41
2323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.92||||2.92|0|2.01|0.41
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.08||||4.08|1.84|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.08||||4.08|2.04|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.08||||4.08|1.63|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.08||||4.08|1.63|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.08||||4.08|1.92|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.08||||4.08|1.67|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.08||||4.08|1.63|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.08||||4.08|2.04|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.08||||4.08|1.84|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.08||||4.08|1.84|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|4.08||||4.08|0.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.08||||4.08|0.57|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.08||||4.08|0|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.08||||4.08|2.82|2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.08||||4.08||2.82|0.57
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.08||||4.08|0|2.82|0.57
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.26||||13.26|5.97|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.26||||13.26|6.63|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.26||||13.26|5.3|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.26||||13.26|5.3|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.26||||13.26|6.23|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.26||||13.26|5.44|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.26||||13.26|5.3|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.26||||13.26|6.63|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.26||||13.26|5.97|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.26||||13.26|5.97|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|13.26||||13.26|2.65|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.26||||13.26|1.86|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.26||||13.26|0|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.26||||13.26|9.15|9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.26||||13.26||9.15|1.86
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.26||||13.26|0|9.15|1.86
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|12.77||||12.77|5.75|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.77||||12.77|6.39|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.77||||12.77|5.11|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.77||||12.77|5.11|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.77||||12.77|6|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.77||||12.77|5.24|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|12.77||||12.77|5.11|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.77||||12.77|6.39|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.77||||12.77|5.75|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.77||||12.77|5.75|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|12.77||||12.77|2.55|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.77||||12.77|1.79|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.77||||12.77|0|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|12.77||||12.77|8.81|8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.77||||12.77||8.81|1.79
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|12.77||||12.77|0|8.81|1.79
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.62||||4.62|2.08|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.62||||4.62|2.31|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.62||||4.62|1.85|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.62||||4.62|1.85|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.62||||4.62|2.17|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.62||||4.62|1.89|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.62||||4.62|1.85|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.62||||4.62|2.31|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.62||||4.62|2.08|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.62||||4.62|2.08|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|Self-pay|Self-pay|4.62||||4.62|0.92|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.62||||4.62|0.65|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.62||||4.62|0|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.62||||4.62|3.19|3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.62||||4.62||3.19|0.65
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.62||||4.62|0|3.19|0.65
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|66||||66|13.2|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AARP [1000]|AARP [100000]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA [1015]|AETNA [101529]|16.5||||16.5|7.43|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMBETTER [2930]|AMBETTER [293000]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.5||||16.5|8.25|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.5||||16.5|6.6|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.5||||16.5|6.6|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.5||||16.5|7.76|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.5||||16.5|6.77|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA PPO [126025]|16.5||||16.5|6.6|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.5||||16.5|8.25|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.5||||16.5|7.43|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.5||||16.5|7.43|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|Self-pay|Self-pay|16.5||||16.5|3.3|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|TML [1980]|TML [198000]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.5||||16.5|2.31|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UNICARE [2040]|UNICARE [204000]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WEB TPA [2115]|WEB TPA [211500]|16.5||||16.5|11.39|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.5||||16.5||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TML WC [212537]|16.5||||16.5|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AARP [1000]|AARP [100000]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AETNA [1015]|AETNA [101529]|29.7||||29.7|13.37|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AMBETTER [2930]|AMBETTER [293000]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.7||||29.7|14.85|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.7||||29.7|11.88|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.7||||29.7|11.88|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.7||||29.7|13.96|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.7||||29.7|12.18|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA [1260]|CIGNA PPO [126025]|29.7||||29.7|11.88|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.7||||29.7|14.85|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.7||||29.7|13.37|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.7||||29.7|13.37|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|Self-pay|Self-pay|29.7||||29.7|5.94|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|TML [1980]|TML [198000]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.7||||29.7|4.16|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|UNICARE [2040]|UNICARE [204000]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.7||||29.7|0|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|WEB TPA [2115]|WEB TPA [211500]|29.7||||29.7|20.49|45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.7||||29.7||45.54|2.31
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|50 mL|WORKER'S COMP [2125]|TML WC [212537]|29.7||||29.7|0|45.54|2.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|36.53||||36.53|16.44|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.53||||36.53|18.27|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.53||||36.53|14.61|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.53||||36.53|14.61|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.53||||36.53|17.17|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.53||||36.53|14.98|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|36.53||||36.53|14.61|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.53||||36.53|18.27|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.53||||36.53|16.44|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.53||||36.53|16.44|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|36.53||||36.53|7.31|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.53||||36.53|5.11|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.53||||36.53|0|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|36.53||||36.53|25.21|25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.53||||36.53||25.21|5.11
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|36.53||||36.53|0|25.21|5.11
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.85||||0.85|0.38|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.85||||0.85|0.43|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.85||||0.85|0.34|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.85||||0.85|0.34|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.85||||0.85|0.4|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.85||||0.85|0.35|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.85||||0.85|0.34|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.85||||0.85|0.43|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.85||||0.85|0.38|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.85||||0.85|0.38|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.85||||0.85|0.17|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.85||||0.85|0.12|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.85||||0.85|0|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.85||||0.85|0.59|0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.85||||0.85||0.59|0.12
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.85||||0.85|0|0.59|0.12
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6||||6|2.7|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6||||6|3|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6||||6|2.4|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6||||6|2.4|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6||||6|2.82|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6||||6|2.46|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6||||6|2.4|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6||||6|3|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6||||6|2.7|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6||||6|2.7|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|6||||6|1.2|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6||||6|0.84|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6||||6|0|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6||||6|4.14|4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6||||6||4.14|0.84
2420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6||||6|0|4.14|0.84
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.37||||0.37|0.17|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.37||||0.37|0.19|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.37||||0.37|0.15|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.37||||0.37|0.15|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.37||||0.37|0.17|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.37||||0.37|0.15|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.37||||0.37|0.15|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.37||||0.37|0.19|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.37||||0.37|0.17|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.37||||0.37|0.17|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.37||||0.37|0.07|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.37||||0.37|0.05|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.37||||0.37|0|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.37||||0.37|0.26|0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.37||||0.37||0.26|0.05
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.37||||0.37|0|0.26|0.05
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.14||||19.14|8.61|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.14||||19.14|9.57|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.14||||19.14|7.66|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.14||||19.14|7.66|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.14||||19.14|9|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.14||||19.14|7.85|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.14||||19.14|7.66|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.14||||19.14|9.57|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.14||||19.14|8.61|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.14||||19.14|8.61|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|Self-pay|Self-pay|19.14||||19.14|3.83|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|TML [1980]|TML [198000]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.14||||19.14|2.68|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.14||||19.14|0|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.14||||19.14|13.21|13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.14||||19.14||13.21|2.68
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.14||||19.14|8.61|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.14||||19.14|9.57|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.14||||19.14|7.66|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.14||||19.14|7.66|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.14||||19.14|9|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.14||||19.14|7.85|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.14||||19.14|7.66|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.14||||19.14|9.57|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.14||||19.14|8.61|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.14||||19.14|8.61|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|Self-pay|Self-pay|19.14||||19.14|3.83|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|TML [1980]|TML [198000]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.14||||19.14|2.68|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.14||||19.14|0|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.14||||19.14|13.21|13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.14||||19.14||13.21|2.68
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.14||||19.14|0|13.21|2.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|33.94||||33.94|15.27|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33.94||||33.94|16.97|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.94||||33.94|13.58|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.94||||33.94|13.58|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.94||||33.94|15.95|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33.94||||33.94|13.92|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|33.94||||33.94|13.58|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33.94||||33.94|16.97|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.94||||33.94|15.27|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.94||||33.94|15.27|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|33.94||||33.94|6.79|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.94||||33.94|4.75|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.94||||33.94|0|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|33.94||||33.94|23.42|23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.94||||33.94||23.42|4.75
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|33.94||||33.94|0|23.42|4.75
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.82||||4.82|2.17|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.82||||4.82|2.41|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.82||||4.82|1.93|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.82||||4.82|1.93|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.82||||4.82|2.27|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.82||||4.82|1.98|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.82||||4.82|1.93|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.82||||4.82|2.41|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.82||||4.82|2.17|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.82||||4.82|2.17|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.82||||4.82|0.96|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.82||||4.82|0.67|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.82||||4.82|0|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.82||||4.82|3.33|3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.82||||4.82||3.33|0.67
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.82||||4.82|0|3.33|0.67
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|6.95||||6.95|3.13|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.95||||6.95|3.48|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.95||||6.95|2.78|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.95||||6.95|2.78|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.95||||6.95|3.27|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.95||||6.95|2.85|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.95||||6.95|2.78|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.95||||6.95|3.48|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.95||||6.95|3.13|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.95||||6.95|3.13|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|6.95||||6.95|1.39|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.95||||6.95|0.97|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.95||||6.95|0|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.95||||6.95|4.8|4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.95||||6.95||4.8|0.97
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.95||||6.95|0|4.8|0.97
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0.08|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.18||||0.18|0.09|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.18||||0.18|0.07|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.18||||0.18|0.07|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.18||||0.18|0.08|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.18||||0.18|0.07|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.18||||0.18|0.07|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.18||||0.18|0.09|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0.08|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.18||||0.18|0.08|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|Self-pay|Self-pay|0.18||||0.18|0.04|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|TML [1980]|TML [198000]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.18||||0.18|0.03|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.18||||0.18|0|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.18||||0.18|0.12|0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.18||||0.18||0.12|0.03
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.18||||0.18|0|0.12|0.03
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|145.2||||145.2|65.34|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|58.08|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|58.08|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|68.24|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|59.53|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|65.34|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|65.34|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|Self-pay|Self-pay|145.2||||145.2|29.04|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|20.33|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2|0|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2||100.19|20.33
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2|0|100.19|20.33
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|353.26||||353.26|158.97|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|353.26||||353.26|176.63|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|353.26||||353.26|141.3|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|353.26||||353.26|141.3|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|353.26||||353.26|166.03|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|353.26||||353.26|144.84|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|353.26||||353.26|141.3|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|353.26||||353.26|176.63|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|353.26||||353.26|158.97|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|353.26||||353.26|158.97|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|353.26||||353.26|70.65|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|353.26||||353.26|49.46|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|353.26||||353.26|0|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|353.26||||353.26|243.75|243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|353.26||||353.26||243.75|49.46
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|353.26||||353.26|0|243.75|49.46
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AARP [1000]|AARP [100000]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AETNA [1015]|AETNA [101529]|6.22||||6.22|2.8|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.22||||6.22|3.11|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.22||||6.22|2.49|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.22||||6.22|2.49|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.22||||6.22|2.92|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.22||||6.22|2.55|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.22||||6.22|2.49|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.22||||6.22|3.11|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.22||||6.22|2.8|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.22||||6.22|2.8|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|Self-pay|Self-pay|6.22||||6.22|1.24|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|TML [1980]|TML [198000]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.22||||6.22|0.87|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.22||||6.22|0|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.22||||6.22|4.29|4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.22||||6.22||4.29|0.87
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.22||||6.22|0|4.29|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|6.18||||6.18|2.78|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.18||||6.18|3.09|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.18||||6.18|2.47|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.18||||6.18|2.47|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.18||||6.18|2.9|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.18||||6.18|2.53|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.18||||6.18|2.47|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.18||||6.18|3.09|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.18||||6.18|2.78|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.18||||6.18|2.78|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|6.18||||6.18|1.24|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TML [1980]|TML [198000]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.18||||6.18|0.87|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.18||||6.18|0|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.18||||6.18|4.26|4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.18||||6.18||4.26|0.87
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.18||||6.18|0|4.26|0.87
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AARP [1000]|AARP [100000]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AETNA [1015]|AETNA [101529]|419.76||||419.76|188.89|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMBETTER [2930]|AMBETTER [293000]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|419.76||||419.76|209.88|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419.76||||419.76|167.9|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419.76||||419.76|167.9|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419.76||||419.76|197.29|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|419.76||||419.76|172.1|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|419.76||||419.76|167.9|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|419.76||||419.76|209.88|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419.76||||419.76|188.89|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419.76||||419.76|188.89|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|Self-pay|Self-pay|419.76||||419.76|83.95|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|TML [1980]|TML [198000]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419.76||||419.76|58.77|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNICARE [2040]|UNICARE [204000]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419.76||||419.76|0|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WEB TPA [2115]|WEB TPA [211500]|419.76||||419.76|289.63|289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419.76||||419.76||289.63|58.77
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|419.76||||419.76|0|289.63|58.77
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AARP [1000]|AARP [100000]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AETNA [1015]|AETNA [101529]|2.74||||2.74|1.23|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMBETTER [2930]|AMBETTER [293000]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.74||||2.74|1.37|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.74||||2.74|1.1|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.74||||2.74|1.1|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.74||||2.74|1.29|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.74||||2.74|1.12|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|2.74||||2.74|1.1|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.74||||2.74|1.37|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.74||||2.74|1.23|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.74||||2.74|1.23|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|Self-pay|Self-pay|2.74||||2.74|0.55|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|TML [1980]|TML [198000]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.74||||2.74|0.38|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UNICARE [2040]|UNICARE [204000]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.74||||2.74|0|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WEB TPA [2115]|WEB TPA [211500]|2.74||||2.74|1.89|1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.74||||2.74||1.89|0.38
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|2.74||||2.74|0|1.89|0.38
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|7.26||||7.26|3.27|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.26||||7.26|3.63|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.26||||7.26|2.9|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.26||||7.26|2.9|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.26||||7.26|3.41|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.26||||7.26|2.98|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|7.26||||7.26|2.9|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.26||||7.26|3.63|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.26||||7.26|3.27|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.26||||7.26|3.27|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|7.26||||7.26|1.45|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.26||||7.26|1.02|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.26||||7.26|0|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|7.26||||7.26|5.01|5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.26||||7.26||5.01|1.02
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|7.26||||7.26|0|5.01|1.02
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.45||||0.45|0.2|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.45||||0.45|0.23|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.45||||0.45|0.18|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.45||||0.45|0.18|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.45||||0.45|0.21|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.45||||0.45|0.18|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|0.45||||0.45|0.18|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.45||||0.45|0.23|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.45||||0.45|0.2|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.45||||0.45|0.2|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.45||||0.45|0.09|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.45||||0.45|0.06|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.45||||0.45|0|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|0.45||||0.45|0.31|0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.45||||0.45||0.31|0.06
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|0.45||||0.45|0|0.31|0.06
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AARP [1000]|AARP [100000]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AETNA [1015]|AETNA [101529]|41.32||||41.32|18.59|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AMBETTER [2930]|AMBETTER [293000]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.32||||41.32|20.66|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.32||||41.32|16.53|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.32||||41.32|16.53|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.32||||41.32|19.42|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.32||||41.32|16.94|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA [1260]|CIGNA PPO [126025]|41.32||||41.32|16.53|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.32||||41.32|20.66|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.32||||41.32|18.59|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.32||||41.32|18.59|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|Self-pay|Self-pay|41.32||||41.32|8.26|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|TML [1980]|TML [198000]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.32||||41.32|5.78|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UNICARE [2040]|UNICARE [204000]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.32||||41.32|0|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WEB TPA [2115]|WEB TPA [211500]|41.32||||41.32|28.51|28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.32||||41.32||28.51|5.78
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WORKER'S COMP [2125]|TML WC [212537]|41.32||||41.32|0|28.51|5.78
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.6||||6.6|2.97|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.6||||6.6|3.3|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.6||||6.6|2.64|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.6||||6.6|2.64|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.6||||6.6|3.1|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.6||||6.6|2.71|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.6||||6.6|2.64|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.6||||6.6|3.3|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.6||||6.6|2.97|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.6||||6.6|2.97|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|Self-pay|Self-pay|6.6||||6.6|1.32|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.6||||6.6|0.92|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.6||||6.6|0|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.6||||6.6|4.55|4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.6||||6.6||4.55|0.92
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.6||||6.6|0|4.55|0.92
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AARP [1000]|AARP [100000]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|80.52||||80.52|36.23|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80.52||||80.52|40.26|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80.52||||80.52|32.21|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80.52||||80.52|32.21|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80.52||||80.52|37.84|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80.52||||80.52|33.01|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|80.52||||80.52|32.21|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80.52||||80.52|40.26|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.52||||80.52|36.23|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80.52||||80.52|36.23|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|Self-pay|Self-pay|80.52||||80.52|16.1|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|TML [1980]|TML [198000]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80.52||||80.52|11.27|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|UNICARE [2040]|UNICARE [204000]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80.52||||80.52|0|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|80.52||||80.52|55.56|55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80.52||||80.52||55.56|11.27
25245|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|80.52||||80.52|0|55.56|11.27
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.63||||15.63|7.03|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.63||||15.63|7.82|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.63||||15.63|6.25|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.63||||15.63|6.25|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.63||||15.63|7.35|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.63||||15.63|6.41|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.63||||15.63|6.25|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.63||||15.63|7.82|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.63||||15.63|7.03|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.63||||15.63|7.03|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|Self-pay|Self-pay|15.63||||15.63|3.13|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.63||||15.63|2.19|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.63||||15.63|0|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.63||||15.63|10.78|10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.63||||15.63||10.78|2.19
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.63||||15.63|0|10.78|2.19
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.07||||13.07|5.88|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.07||||13.07|6.54|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.07||||13.07|5.23|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.07||||13.07|5.23|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.07||||13.07|6.14|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.07||||13.07|5.36|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.07||||13.07|5.23|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.07||||13.07|6.54|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.07||||13.07|5.88|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.07||||13.07|5.88|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|Self-pay|Self-pay|13.07||||13.07|2.61|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.07||||13.07|1.83|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.07||||13.07|0|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.07||||13.07|9.02|9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.07||||13.07||9.02|1.83
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.07||||13.07|0|9.02|1.83
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|13.81||||13.81|6.21|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.81||||13.81|6.91|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.81||||13.81|5.52|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.81||||13.81|5.52|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.81||||13.81|6.49|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.81||||13.81|5.66|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|13.81||||13.81|5.52|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.81||||13.81|6.91|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.81||||13.81|6.21|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.81||||13.81|6.21|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|13.81||||13.81|2.76|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.81||||13.81|1.93|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.81||||13.81|0|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|13.81||||13.81|9.53|9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.81||||13.81||9.53|1.93
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|13.81||||13.81|0|9.53|1.93
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|9.84||||9.84|4.43|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.84||||9.84|4.92|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.84||||9.84|3.94|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.84||||9.84|3.94|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.84||||9.84|4.62|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.84||||9.84|4.03|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.84||||9.84|3.94|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.84||||9.84|4.92|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.84||||9.84|4.43|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.84||||9.84|4.43|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|9.84||||9.84|1.97|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.84||||9.84|1.38|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.84||||9.84|0|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.84||||9.84|6.79|6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.84||||9.84||6.79|1.38
2551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.84||||9.84|0|6.79|1.38
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3||||3|1.35|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3||||3|1.5|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3||||3|1.2|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3||||3|1.2|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3||||3|1.41|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3||||3|1.23|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3||||3|1.2|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3||||3|1.5|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3||||3|1.35|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3||||3|1.35|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|3||||3|0.6|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3||||3|0.42|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3||||3|0|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3||||3|2.07|2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3||||3||2.07|0.42
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3||||3|0|2.07|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.97||||2.97|1.34|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.97||||2.97|1.49|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.97||||2.97|1.19|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.97||||2.97|1.19|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.97||||2.97|1.4|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.97||||2.97|1.22|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.97||||2.97|1.19|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.97||||2.97|1.49|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.97||||2.97|1.34|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.97||||2.97|1.34|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|2.97||||2.97|0.59|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.97||||2.97|0.42|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.97||||2.97|0|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.97||||2.97|2.05|2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.97||||2.97||2.05|0.42
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.97||||2.97|0|2.05|0.42
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.79|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.76||||1.76|0.88|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.7|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.7|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|0.83|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.76||||1.76|0.72|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.76||||1.76|0.7|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.76||||1.76|0.88|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.79|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.79|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|Self-pay|Self-pay|1.76||||1.76|0.35|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.25|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76|0|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.76||||1.76|1.21|1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||1.21|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.76||||1.76|0|1.21|0.25
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.79||||2.79|1.26|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.79||||2.79|1.4|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.79||||2.79|1.12|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.12|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.79||||2.79|1.31|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.79||||2.79|1.14|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.79||||2.79|1.12|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.79||||2.79|1.4|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|1.26|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|1.26|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.79||||2.79|0.56|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.79||||2.79|0.39|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79|0|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.79||||2.79|1.93|1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.79||||2.79||1.93|0.39
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.79||||2.79|0|1.93|0.39
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|6.18||||6.18|2.78|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.18||||6.18|3.09|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.18||||6.18|2.47|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.18||||6.18|2.47|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.18||||6.18|2.9|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.18||||6.18|2.53|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.18||||6.18|2.47|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.18||||6.18|3.09|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.18||||6.18|2.78|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.18||||6.18|2.78|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|6.18||||6.18|1.24|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.18||||6.18|0.87|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.18||||6.18|0|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.18||||6.18|4.26|4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.18||||6.18||4.26|0.87
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.18||||6.18|0|4.26|0.87
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AARP [1000]|AARP [100000]|404.39||||404.39|404.39|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AETNA [1015]|AETNA [101529]|404.39||||404.39|181.98|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AMBETTER [2930]|AMBETTER [293000]|404.39||||404.39|43.6|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|404.39||||404.39|202.2|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|404.39||||404.39|161.76|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|404.39||||404.39|161.76|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|404.39||||404.39|190.06|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|404.39||||404.39|165.8|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA [1260]|CIGNA PPO [126025]|404.39||||404.39|161.76|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|404.39||||404.39|404.39|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|404.39||||404.39|202.2|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|404.39||||404.39|181.98|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|404.39||||404.39|181.98|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|404.39||||404.39|0|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|Self-pay|Self-pay|404.39||||404.39|80.88|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|TML [1980]|TML [198000]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|404.39||||404.39|56.61|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|404.39||||404.39|404.39|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UNICARE [2040]|UNICARE [204000]|404.39||||404.39|404.39|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|404.39||||404.39|404.39|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WEB TPA [2115]|WEB TPA [211500]|404.39||||404.39|279.03|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|404.39||||404.39|41.53|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|404.39||||404.39|83.06|404.39|41.53
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WORKER'S COMP [2125]|TML WC [212537]|404.39||||404.39|404.39|404.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AARP [1000]|AARP [100000]|299.39||||299.39|299.39|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AETNA [1015]|AETNA [101529]|299.39||||299.39|134.73|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AMBETTER [2930]|AMBETTER [293000]|299.39||||299.39|43.6|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|299.39||||299.39|149.7|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299.39||||299.39|119.76|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299.39||||299.39|119.76|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299.39||||299.39|140.71|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|299.39||||299.39|122.75|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA [1260]|CIGNA PPO [126025]|299.39||||299.39|119.76|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|299.39||||299.39|299.39|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|299.39||||299.39|149.7|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299.39||||299.39|134.73|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299.39||||299.39|134.73|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299.39||||299.39|0|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|Self-pay|Self-pay|299.39||||299.39|59.88|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|TML [1980]|TML [198000]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299.39||||299.39|41.91|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299.39||||299.39|299.39|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UNICARE [2040]|UNICARE [204000]|299.39||||299.39|299.39|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299.39||||299.39|299.39|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WEB TPA [2115]|WEB TPA [211500]|299.39||||299.39|206.58|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299.39||||299.39|41.53|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299.39||||299.39|83.06|299.39|41.53
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WORKER'S COMP [2125]|TML WC [212537]|299.39||||299.39|299.39|299.39|41.53
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|9.27||||9.27|4.17|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.27||||9.27|4.64|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.27||||9.27|3.71|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.27||||9.27|3.71|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.27||||9.27|4.36|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.27||||9.27|3.8|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|9.27||||9.27|3.71|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.27||||9.27|4.64|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.27||||9.27|4.17|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.27||||9.27|4.17|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|9.27||||9.27|1.85|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.27||||9.27|1.3|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.27||||9.27|0|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|9.27||||9.27|6.4|6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.27||||9.27||6.4|1.3
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|9.27||||9.27|0|6.4|1.3
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AARP [1000]|AARP [100000]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|318.92||||318.92|143.51|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMBETTER [2930]|AMBETTER [293000]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|318.92||||318.92|159.46|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|318.92||||318.92|127.57|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|318.92||||318.92|127.57|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|318.92||||318.92|149.89|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|318.92||||318.92|130.76|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA [1260]|CIGNA PPO [126025]|318.92||||318.92|127.57|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|318.92||||318.92|159.46|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|318.92||||318.92|143.51|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|318.92||||318.92|143.51|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|Self-pay|Self-pay|318.92||||318.92|63.78|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|TML [1980]|TML [198000]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|318.92||||318.92|44.65|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNICARE [2040]|UNICARE [204000]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|318.92||||318.92|0|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WEB TPA [2115]|WEB TPA [211500]|318.92||||318.92|220.05|220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|318.92||||318.92||220.05|44.65
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WORKER'S COMP [2125]|TML WC [212537]|318.92||||318.92|0|220.05|44.65
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.35||||2.35|1.06|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.35||||2.35|1.18|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.35||||2.35|0.94|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.35||||2.35|0.94|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.35||||2.35|1.1|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.35||||2.35|0.96|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.35||||2.35|0.94|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.35||||2.35|1.18|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.35||||2.35|1.06|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.35||||2.35|1.06|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|2.35||||2.35|0.47|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.35||||2.35|0.33|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.35||||2.35|0|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.35||||2.35|1.62|1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.35||||2.35||1.62|0.33
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.35||||2.35|0|1.62|0.33
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AARP [1000]|AARP [100000]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA [1015]|AETNA [101529]|66.33||||66.33|29.85|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMBETTER [2930]|AMBETTER [293000]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.33||||66.33|33.17|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.33||||66.33|26.53|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.33||||66.33|26.53|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.33||||66.33|31.18|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.33||||66.33|27.2|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA [1260]|CIGNA PPO [126025]|66.33||||66.33|26.53|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.33||||66.33|33.17|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.33||||66.33|29.85|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.33||||66.33|29.85|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|Self-pay|Self-pay|66.33||||66.33|13.27|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|TML [1980]|TML [198000]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.33||||66.33|9.29|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNICARE [2040]|UNICARE [204000]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.33||||66.33|0|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WEB TPA [2115]|WEB TPA [211500]|66.33||||66.33|45.77|45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.33||||66.33||45.77|9.29
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WORKER'S COMP [2125]|TML WC [212537]|66.33||||66.33|0|45.77|9.29
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|11.9||||11.9|5.36|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.9||||11.9|5.95|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.9||||11.9|4.76|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.9||||11.9|4.76|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.9||||11.9|5.59|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.9||||11.9|4.88|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|11.9||||11.9|4.76|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.9||||11.9|5.95|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.9||||11.9|5.36|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.9||||11.9|5.36|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|11.9||||11.9|2.38|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.9||||11.9|1.67|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.9||||11.9|0|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|11.9||||11.9|8.21|8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.9||||11.9||8.21|1.67
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|11.9||||11.9|0|8.21|1.67
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|47.21||||47.21|21.24|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.21||||47.21|23.61|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.21||||47.21|18.88|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.21||||47.21|18.88|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.21||||47.21|22.19|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|47.21||||47.21|19.36|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|47.21||||47.21|18.88|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.21||||47.21|23.61|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.21||||47.21|21.24|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.21||||47.21|21.24|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|47.21||||47.21|9.44|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.21||||47.21|6.61|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.21||||47.21|0|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|47.21||||47.21|32.57|32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.21||||47.21||32.57|6.61
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|47.21||||47.21|0|32.57|6.61
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|9.61||||9.61|4.32|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.61||||9.61|4.81|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.61||||9.61|3.84|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.61||||9.61|3.84|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.61||||9.61|4.52|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.61||||9.61|3.94|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.61||||9.61|3.84|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.61||||9.61|4.81|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.61||||9.61|4.32|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.61||||9.61|4.32|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|9.61||||9.61|1.92|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.61||||9.61|1.35|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.61||||9.61|0|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.61||||9.61|6.63|6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.61||||9.61||6.63|1.35
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.61||||9.61|0|6.63|1.35
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|59.4||||59.4|26.73|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.4||||59.4|23.76|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.4||||59.4|23.76|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.4||||59.4|27.92|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|24.35|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|26.73|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|26.73|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|59.4||||59.4|11.88|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.4||||59.4|8.32|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4|0|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.4||||59.4||40.99|8.32
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4|0|40.99|8.32
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|41.72||||41.72|18.77|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.72||||41.72|20.86|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.72||||41.72|16.69|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.72||||41.72|16.69|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.72||||41.72|19.61|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.72||||41.72|17.11|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|41.72||||41.72|16.69|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.72||||41.72|20.86|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.72||||41.72|18.77|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.72||||41.72|18.77|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|41.72||||41.72|8.34|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.72||||41.72|5.84|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.72||||41.72|0|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|41.72||||41.72|28.79|28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.72||||41.72||28.79|5.84
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|41.72||||41.72|0|28.79|5.84
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.57||||3.57|1.61|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.57||||3.57|1.79|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.57||||3.57|1.43|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.57||||3.57|1.43|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.57||||3.57|1.68|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.57||||3.57|1.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.57||||3.57|1.43|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.57||||3.57|1.79|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.57||||3.57|1.61|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.57||||3.57|1.61|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|Self-pay|Self-pay|3.57||||3.57|0.71|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.57||||3.57|0.5|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.57||||3.57|0|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.57||||3.57|2.46|2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.57||||3.57||2.46|0.5
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.57||||3.57|0|2.46|0.5
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AARP [1000]|AARP [100000]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AETNA [1015]|AETNA [101529]|23||||23|10.35|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMBETTER [2930]|AMBETTER [293000]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23||||23|11.5|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|9.2|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|9.2|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|10.81|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23||||23|9.43|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA [1260]|CIGNA PPO [126025]|23||||23|9.2|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23||||23|11.5|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|10.35|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|10.35|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|Self-pay|Self-pay|23||||23|4.6|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|TML [1980]|TML [198000]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23|3.22|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UNICARE [2040]|UNICARE [204000]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23|0|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WEB TPA [2115]|WEB TPA [211500]|23||||23|15.87|15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23||15.87|3.22
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WORKER'S COMP [2125]|TML WC [212537]|23||||23|0|15.87|3.22
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AARP [1000]|AARP [100000]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AETNA [1015]|AETNA [101529]|13||||13|5.85|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMBETTER [2930]|AMBETTER [293000]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13||||13|6.5|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13||||13|5.2|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13||||13|5.2|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13||||13|6.11|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13||||13|5.33|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA [1260]|CIGNA PPO [126025]|13||||13|5.2|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13||||13|6.5|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13||||13|5.85|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13||||13|5.85|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|Self-pay|Self-pay|13||||13|2.6|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|TML [1980]|TML [198000]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13||||13|1.82|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UNICARE [2040]|UNICARE [204000]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13||||13|0|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WEB TPA [2115]|WEB TPA [211500]|13||||13|8.97|8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13||||13||8.97|1.82
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WORKER'S COMP [2125]|TML WC [212537]|13||||13|0|8.97|1.82
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AARP [1000]|AARP [100000]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AETNA [1015]|AETNA [101529]|277||||277|124.65|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AMBETTER [2930]|AMBETTER [293000]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277||||277|138.5|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277||||277|110.8|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277||||277|110.8|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277||||277|130.19|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277||||277|113.57|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|CIGNA [1260]|CIGNA PPO [126025]|277||||277|110.8|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277||||277|138.5|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277||||277|124.65|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277||||277|124.65|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|Self-pay|Self-pay|277||||277|55.4|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|TML [1980]|TML [198000]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277||||277|38.78|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|UNICARE [2040]|UNICARE [204000]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277||||277|0|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|WEB TPA [2115]|WEB TPA [211500]|277||||277|191.13|191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277||||277||191.13|38.78
27010091|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BREATHER|1|WORKER'S COMP [2125]|TML WC [212537]|277||||277|0|191.13|38.78
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AARP [1000]|AARP [100000]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AETNA [1015]|AETNA [101529]|30||||30|13.5|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AMBETTER [2930]|AMBETTER [293000]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|30||||30|15|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30||||30|12|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30||||30|12|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30||||30|14.1|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|30||||30|12.3|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|CIGNA [1260]|CIGNA PPO [126025]|30||||30|12|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|GROUP PENSION ADMIN [1450]|GPA [145000]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|30||||30|15|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30||||30|13.5|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30||||30|13.5|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|PHCS [1780]|PHCS MULTIPLAN [178000]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|Self-pay|Self-pay|30||||30|6|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|TML [1980]|TML [198000]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30||||30|4.2|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|UNICARE [2040]|UNICARE [204000]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30||||30|0|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|WEB TPA [2115]|WEB TPA [211500]|30||||30|20.7|20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30||||30||20.7|4.2
27010096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANISTER SUCTION 3300 ML|1|WORKER'S COMP [2125]|TML WC [212537]|30||||30|0|20.7|4.2
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AARP [1000]|AARP [100000]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AETNA [1015]|AETNA [101529]|60||||60|27|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMBETTER [2930]|AMBETTER [293000]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|60||||60|30|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|24|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|24|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|28.2|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|60||||60|24.6|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA [1260]|CIGNA PPO [126025]|60||||60|24|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|60||||60|30|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|27|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|27|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|Self-pay|Self-pay|60||||60|12|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|TML [1980]|TML [198000]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60|8.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UNICARE [2040]|UNICARE [204000]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60|0|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WEB TPA [2115]|WEB TPA [211500]|60||||60|41.4|41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60||41.4|8.4
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WORKER'S COMP [2125]|TML WC [212537]|60||||60|0|41.4|8.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AARP [1000]|AARP [100000]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA [1015]|AETNA [101529]|27||||27|12.15|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMBETTER [2930]|AMBETTER [293000]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27||||27|13.5|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27||||27|10.8|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27||||27|10.8|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27||||27|12.69|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27||||27|11.07|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA [1260]|CIGNA PPO [126025]|27||||27|10.8|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27||||27|13.5|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|12.15|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|12.15|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|Self-pay|Self-pay|27||||27|5.4|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|TML [1980]|TML [198000]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27||||27|3.78|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNICARE [2040]|UNICARE [204000]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27|0|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WEB TPA [2115]|WEB TPA [211500]|27||||27|18.63|18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27||||27||18.63|3.78
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WORKER'S COMP [2125]|TML WC [212537]|27||||27|0|18.63|3.78
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AARP [1000]|AARP [100000]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AETNA [1015]|AETNA [101529]|266||||266|119.7|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AMBETTER [2930]|AMBETTER [293000]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|266||||266|133|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|266||||266|106.4|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|266||||266|106.4|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|266||||266|125.02|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|266||||266|109.06|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|CIGNA [1260]|CIGNA PPO [126025]|266||||266|106.4|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|266||||266|133|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|266||||266|119.7|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|266||||266|119.7|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|Self-pay|Self-pay|266||||266|53.2|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|TML [1980]|TML [198000]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|266||||266|37.24|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|UNICARE [2040]|UNICARE [204000]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|266||||266|0|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|WEB TPA [2115]|WEB TPA [211500]|266||||266|183.54|183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|266||||266||183.54|37.24
27010189|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FLUTTER VALVE|1|WORKER'S COMP [2125]|TML WC [212537]|266||||266|0|183.54|37.24
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AARP [1000]|AARP [100000]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AETNA [1015]|AETNA [101529]|209||||209|94.05|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AMBETTER [2930]|AMBETTER [293000]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209||||209|104.5|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|83.6|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|83.6|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|98.23|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209||||209|85.69|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|CIGNA [1260]|CIGNA PPO [126025]|209||||209|83.6|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209||||209|104.5|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|94.05|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|94.05|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|Self-pay|Self-pay|209||||209|41.8|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|TML [1980]|TML [198000]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|29.26|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|UNICARE [2040]|UNICARE [204000]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209|0|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|WEB TPA [2115]|WEB TPA [211500]|209||||209|144.21|144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209||144.21|29.26
27010284|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE LG|1|WORKER'S COMP [2125]|TML WC [212537]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AARP [1000]|AARP [100000]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AETNA [1015]|AETNA [101529]|209||||209|94.05|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMBETTER [2930]|AMBETTER [293000]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209||||209|104.5|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|83.6|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|83.6|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|98.23|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209||||209|85.69|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA [1260]|CIGNA PPO [126025]|209||||209|83.6|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209||||209|104.5|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|94.05|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|94.05|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|Self-pay|Self-pay|209||||209|41.8|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|TML [1980]|TML [198000]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|29.26|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UNICARE [2040]|UNICARE [204000]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209|0|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WEB TPA [2115]|WEB TPA [211500]|209||||209|144.21|144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209||144.21|29.26
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WORKER'S COMP [2125]|TML WC [212537]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AARP [1000]|AARP [100000]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AETNA [1015]|AETNA [101529]|209||||209|94.05|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AMBETTER [2930]|AMBETTER [293000]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209||||209|104.5|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|83.6|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|83.6|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|98.23|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209||||209|85.69|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|CIGNA [1260]|CIGNA PPO [126025]|209||||209|83.6|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209||||209|104.5|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|94.05|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|94.05|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|Self-pay|Self-pay|209||||209|41.8|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|TML [1980]|TML [198000]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|29.26|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|UNICARE [2040]|UNICARE [204000]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209|0|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|WEB TPA [2115]|WEB TPA [211500]|209||||209|144.21|144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209||144.21|29.26
27010286|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE SM|1|WORKER'S COMP [2125]|TML WC [212537]|209||||209|0|144.21|29.26
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AARP [1000]|AARP [100000]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AETNA [1015]|AETNA [101529]|13||||13|5.85|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMBETTER [2930]|AMBETTER [293000]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13||||13|6.5|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13||||13|5.2|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13||||13|5.2|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13||||13|6.11|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13||||13|5.33|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA [1260]|CIGNA PPO [126025]|13||||13|5.2|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13||||13|6.5|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13||||13|5.85|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13||||13|5.85|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|Self-pay|Self-pay|13||||13|2.6|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|TML [1980]|TML [198000]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13||||13|1.82|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UNICARE [2040]|UNICARE [204000]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13||||13|0|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WEB TPA [2115]|WEB TPA [211500]|13||||13|8.97|8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13||||13||8.97|1.82
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WORKER'S COMP [2125]|TML WC [212537]|13||||13|0|8.97|1.82
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AARP [1000]|AARP [100000]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AETNA [1015]|AETNA [101529]|39||||39|17.55|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMBETTER [2930]|AMBETTER [293000]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39||||39|19.5|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39||||39|15.6|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39||||39|15.6|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39||||39|18.33|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39||||39|15.99|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA [1260]|CIGNA PPO [126025]|39||||39|15.6|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39||||39|19.5|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39||||39|17.55|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39||||39|17.55|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|Self-pay|Self-pay|39||||39|7.8|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|TML [1980]|TML [198000]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39||||39|5.46|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UNICARE [2040]|UNICARE [204000]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39||||39|0|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WEB TPA [2115]|WEB TPA [211500]|39||||39|26.91|26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39||||39||26.91|5.46
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WORKER'S COMP [2125]|TML WC [212537]|39||||39|0|26.91|5.46
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AARP [1000]|AARP [100000]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AETNA [1015]|AETNA [101529]|95||||95|42.75|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AMBETTER [2930]|AMBETTER [293000]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|95||||95|47.5|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95||||95|38|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95||||95|38|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95||||95|44.65|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|95||||95|38.95|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|CIGNA [1260]|CIGNA PPO [126025]|95||||95|38|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|95||||95|47.5|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95||||95|42.75|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95||||95|42.75|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|Self-pay|Self-pay|95||||95|19|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|TML [1980]|TML [198000]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95||||95|13.3|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|UNICARE [2040]|UNICARE [204000]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95||||95|0|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|WEB TPA [2115]|WEB TPA [211500]|95||||95|65.55|65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95||||95||65.55|13.3
27010309|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METER PEAK FLOW|1|WORKER'S COMP [2125]|TML WC [212537]|95||||95|0|65.55|13.3
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AARP [1000]|AARP [100000]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA [1015]|AETNA [101529]|300||||300|135|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMBETTER [2930]|AMBETTER [293000]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|300||||300|150|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|120|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|120|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|141|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|300||||300|123|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA [1260]|CIGNA PPO [126025]|300||||300|120|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|300||||300|150|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|135|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|135|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|Self-pay|Self-pay|300||||300|60|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|TML [1980]|TML [198000]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|42|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNICARE [2040]|UNICARE [204000]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|0|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WEB TPA [2115]|WEB TPA [211500]|300||||300|207|207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||207|42
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WORKER'S COMP [2125]|TML WC [212537]|300||||300|0|207|42
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AARP [1000]|AARP [100000]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AETNA [1015]|AETNA [101529]|23||||23|10.35|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AMBETTER [2930]|AMBETTER [293000]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23||||23|11.5|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|9.2|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|9.2|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|10.81|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23||||23|9.43|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|CIGNA [1260]|CIGNA PPO [126025]|23||||23|9.2|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23||||23|11.5|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|10.35|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|10.35|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|Self-pay|Self-pay|23||||23|4.6|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|TML [1980]|TML [198000]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23|3.22|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|UNICARE [2040]|UNICARE [204000]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23|0|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|WEB TPA [2115]|WEB TPA [211500]|23||||23|15.87|15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23||15.87|3.22
27010365|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INCENTIVE SPIROMETER|1|WORKER'S COMP [2125]|TML WC [212537]|23||||23|0|15.87|3.22
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AARP [1000]|AARP [100000]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AETNA [1015]|AETNA [101529]|77||||77|34.65|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AMBETTER [2930]|AMBETTER [293000]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|77||||77|38.5|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77||||77|30.8|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77||||77|30.8|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77||||77|36.19|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|77||||77|31.57|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|CIGNA [1260]|CIGNA PPO [126025]|77||||77|30.8|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|GROUP PENSION ADMIN [1450]|GPA [145000]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|77||||77|38.5|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77||||77|34.65|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77||||77|34.65|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|PHCS [1780]|PHCS MULTIPLAN [178000]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|Self-pay|Self-pay|77||||77|15.4|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|TML [1980]|TML [198000]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77||||77|10.78|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|UNICARE [2040]|UNICARE [204000]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77||||77|0|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|WEB TPA [2115]|WEB TPA [211500]|77||||77|53.13|53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77||||77||53.13|10.78
27010376|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER MINIHEART|1|WORKER'S COMP [2125]|TML WC [212537]|77||||77|0|53.13|10.78
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AARP [1000]|AARP [100000]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AETNA [1015]|AETNA [101529]|69||||69|31.05|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AMBETTER [2930]|AMBETTER [293000]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|34.5|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|27.6|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|27.6|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|32.43|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|28.29|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|34.5|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|31.05|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|31.05|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|Self-pay|Self-pay|69||||69|13.8|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|TML [1980]|TML [198000]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|9.66|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|UNICARE [2040]|UNICARE [204000]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|0|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69||47.61|9.66
27010384|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VALVE PEEP|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|0|47.61|9.66
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AARP [1000]|AARP [100000]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AETNA [1015]|AETNA [101529]|265||||265|119.25|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMBETTER [2930]|AMBETTER [293000]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|265||||265|132.5|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|265||||265|106|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|265||||265|106|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|265||||265|124.55|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|265||||265|108.65|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA [1260]|CIGNA PPO [126025]|265||||265|106|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|265||||265|132.5|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|265||||265|119.25|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|265||||265|119.25|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|Self-pay|Self-pay|265||||265|53|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|TML [1980]|TML [198000]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|265||||265|37.1|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UNICARE [2040]|UNICARE [204000]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|265||||265|0|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WEB TPA [2115]|WEB TPA [211500]|265||||265|182.85|182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|265||||265||182.85|37.1
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WORKER'S COMP [2125]|TML WC [212537]|265||||265|0|182.85|37.1
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AARP [1000]|AARP [100000]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AETNA [1015]|AETNA [101529]|218||||218|98.1|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AMBETTER [2930]|AMBETTER [293000]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|218||||218|109|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|218||||218|87.2|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|218||||218|87.2|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|218||||218|102.46|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|218||||218|89.38|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|CIGNA [1260]|CIGNA PPO [126025]|218||||218|87.2|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|218||||218|109|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|218||||218|98.1|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|218||||218|98.1|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|Self-pay|Self-pay|218||||218|43.6|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|TML [1980]|TML [198000]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|218||||218|30.52|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|UNICARE [2040]|UNICARE [204000]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|218||||218|0|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|WEB TPA [2115]|WEB TPA [211500]|218||||218|150.42|150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|218||||218||150.42|30.52
27010469|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRIST COCK UP XLRG LEFT|1|WORKER'S COMP [2125]|TML WC [212537]|218||||218|0|150.42|30.52
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AARP [1000]|AARP [100000]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AETNA [1015]|AETNA [101529]|667||||667|300.15|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMBETTER [2930]|AMBETTER [293000]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|667||||667|333.5|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|667||||667|266.8|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|667||||667|266.8|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|667||||667|313.49|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|667||||667|273.47|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA [1260]|CIGNA PPO [126025]|667||||667|266.8|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|667||||667|333.5|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|667||||667|300.15|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|667||||667|300.15|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|Self-pay|Self-pay|667||||667|133.4|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|TML [1980]|TML [198000]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|667||||667|93.38|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UNICARE [2040]|UNICARE [204000]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|667||||667|0|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WEB TPA [2115]|WEB TPA [211500]|667||||667|460.23|460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|667||||667||460.23|93.38
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WORKER'S COMP [2125]|TML WC [212537]|667||||667|0|460.23|93.38
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.82||||2.82|1.27|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.82||||2.82|1.41|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.82||||2.82|1.13|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.82||||2.82|1.13|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.82||||2.82|1.33|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.82||||2.82|1.16|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.82||||2.82|1.13|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.82||||2.82|1.41|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.82||||2.82|1.27|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.82||||2.82|1.27|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.82||||2.82|0.56|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.82||||2.82|0.39|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.82||||2.82|0|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.82||||2.82|1.95|1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.82||||2.82||1.95|0.39
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.82||||2.82|0|1.95|0.39
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AARP [1000]|AARP [100000]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AETNA [1015]|AETNA [101529]|184||||184|82.8|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMBETTER [2930]|AMBETTER [293000]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184||||184|92|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184|73.6|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184|73.6|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184|86.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184||||184|75.44|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA [1260]|CIGNA PPO [126025]|184||||184|73.6|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184||||184|92|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|82.8|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|82.8|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|Self-pay|Self-pay|184||||184|36.8|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|TML [1980]|TML [198000]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|25.76|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UNICARE [2040]|UNICARE [204000]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184|0|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WEB TPA [2115]|WEB TPA [211500]|184||||184|126.96|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184|37.48|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184|1.7|126.96|1.7
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WORKER'S COMP [2125]|TML WC [212537]|184||||184|0|126.96|1.7
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AARP [1000]|AARP [100000]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AETNA [1015]|AETNA [101529]|170||||170|76.5|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMBETTER [2930]|AMBETTER [293000]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|170||||170|85|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170||||170|68|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170||||170|68|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170||||170|79.9|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|170||||170|69.7|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA [1260]|CIGNA PPO [126025]|170||||170|68|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|GROUP PENSION ADMIN [1450]|GPA [145000]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|170||||170|85|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170||||170|76.5|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170||||170|76.5|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|PHCS [1780]|PHCS MULTIPLAN [178000]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|Self-pay|Self-pay|170||||170|34|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|TML [1980]|TML [198000]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170||||170|23.8|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UNICARE [2040]|UNICARE [204000]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170||||170|0|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WEB TPA [2115]|WEB TPA [211500]|170||||170|117.3|117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170||||170||117.3|23.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WORKER'S COMP [2125]|TML WC [212537]|170||||170|0|117.3|23.8
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AARP [1000]|AARP [100000]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AETNA [1015]|AETNA [101529]|25||||25|11.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMBETTER [2930]|AMBETTER [293000]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25||||25|12.5|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|10|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|10|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|11.75|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25||||25|10.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA [1260]|CIGNA PPO [126025]|25||||25|10|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25||||25|12.5|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|11.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|11.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|Self-pay|Self-pay|25||||25|5|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|TML [1980]|TML [198000]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|3.5|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UNICARE [2040]|UNICARE [204000]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25|0|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WEB TPA [2115]|WEB TPA [211500]|25||||25|17.25|17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25||17.25|3.5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WORKER'S COMP [2125]|TML WC [212537]|25||||25|0|17.25|3.5
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AARP [1000]|AARP [100000]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AETNA [1015]|AETNA [101529]|134||||134|60.3|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMBETTER [2930]|AMBETTER [293000]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|134||||134|67|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134||||134|53.6|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134||||134|53.6|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134||||134|62.98|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|134||||134|54.94|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA [1260]|CIGNA PPO [126025]|134||||134|53.6|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|134||||134|67|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134||||134|60.3|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134||||134|60.3|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|Self-pay|Self-pay|134||||134|26.8|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|TML [1980]|TML [198000]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134||||134|18.76|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UNICARE [2040]|UNICARE [204000]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134||||134|0|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WEB TPA [2115]|WEB TPA [211500]|134||||134|92.46|92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134||||134||92.46|18.76
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WORKER'S COMP [2125]|TML WC [212537]|134||||134|0|92.46|18.76
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|2.88|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|1.7|7.59|1.54
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AARP [1000]|AARP [100000]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AETNA [1015]|AETNA [101529]|11||||11|4.95|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMBETTER [2930]|AMBETTER [293000]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|4.4|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|4.4|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.17|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|4.51|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.95|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.95|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|Self-pay|Self-pay|11||||11|2.2|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|TML [1980]|TML [198000]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|1.54|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UNICARE [2040]|UNICARE [204000]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|0|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|1.54
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|0|7.59|1.54
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AARP [1000]|AARP [100000]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AETNA [1015]|AETNA [101529]|545.25||||545.25|245.36|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AMBETTER [2930]|AMBETTER [293000]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.25||||545.25|272.63|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.25||||545.25|218.1|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.25||||545.25|218.1|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.25||||545.25|256.27|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.25||||545.25|223.55|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|CIGNA [1260]|CIGNA PPO [126025]|545.25||||545.25|218.1|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.25||||545.25|272.63|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.25||||545.25|245.36|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.25||||545.25|245.36|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|Self-pay|Self-pay|545.25||||545.25|109.05|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|TML [1980]|TML [198000]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.25||||545.25|76.34|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|UNICARE [2040]|UNICARE [204000]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.25||||545.25|0|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|WEB TPA [2115]|WEB TPA [211500]|545.25||||545.25|376.22|376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.25||||545.25||376.22|76.34
27211754|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ANTI-TRIGGER/MP BLOCK|1|WORKER'S COMP [2125]|TML WC [212537]|545.25||||545.25|0|376.22|76.34
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AARP [1000]|AARP [100000]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AETNA [1015]|AETNA [101529]|33||||33|14.85|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMBETTER [2930]|AMBETTER [293000]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|13.2|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|13.2|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|15.51|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|13.53|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|14.85|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|14.85|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|Self-pay|Self-pay|33||||33|6.6|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|TML [1980]|TML [198000]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|4.62|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNICARE [2040]|UNICARE [204000]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|0|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33||22.77|4.62
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WORKER'S COMP [2125]|TML WC [212537]|33||||33|0|22.77|4.62
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AARP [1000]|AARP [100000]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AETNA [1015]|AETNA [101529]|499.25||||499.25|224.66|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AMBETTER [2930]|AMBETTER [293000]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|499.25||||499.25|249.63|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499.25||||499.25|199.7|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499.25||||499.25|199.7|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499.25||||499.25|234.65|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|499.25||||499.25|204.69|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|CIGNA [1260]|CIGNA PPO [126025]|499.25||||499.25|199.7|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|499.25||||499.25|249.63|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499.25||||499.25|224.66|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499.25||||499.25|224.66|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|Self-pay|Self-pay|499.25||||499.25|99.85|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|TML [1980]|TML [198000]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499.25||||499.25|69.9|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|UNICARE [2040]|UNICARE [204000]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499.25||||499.25|0|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|WEB TPA [2115]|WEB TPA [211500]|499.25||||499.25|344.48|344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499.25||||499.25||344.48|69.9
27400003|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|CERVICAL COLLAR (TLSO) 2 ANTERIOR COMPONENTS|1|WORKER'S COMP [2125]|TML WC [212537]|499.25||||499.25|0|344.48|69.9
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AARP [1000]|AARP [100000]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AETNA [1015]|AETNA [101529]|681.5||||681.5|306.68|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AMBETTER [2930]|AMBETTER [293000]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|681.5||||681.5|340.75|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|681.5||||681.5|272.6|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|681.5||||681.5|272.6|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|681.5||||681.5|320.31|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|681.5||||681.5|279.42|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|CIGNA [1260]|CIGNA PPO [126025]|681.5||||681.5|272.6|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|681.5||||681.5|340.75|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|681.5||||681.5|306.68|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|681.5||||681.5|306.68|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|Self-pay|Self-pay|681.5||||681.5|136.3|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|TML [1980]|TML [198000]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|681.5||||681.5|95.41|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|UNICARE [2040]|UNICARE [204000]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|681.5||||681.5|0|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|WEB TPA [2115]|WEB TPA [211500]|681.5||||681.5|470.24|470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|681.5||||681.5||470.24|95.41
27400008|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|ANKL ORTHOSIS/GAUNTLET OR SIMLR W/W-O JNTS PREFAB OTS|1|WORKER'S COMP [2125]|TML WC [212537]|681.5||||681.5|0|470.24|95.41
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AARP [1000]|AARP [100000]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AETNA [1015]|AETNA [101529]|454||||454|204.3|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AMBETTER [2930]|AMBETTER [293000]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|454||||454|227|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|454||||454|181.6|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|454||||454|181.6|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|454||||454|213.38|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|454||||454|186.14|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|CIGNA [1260]|CIGNA PPO [126025]|454||||454|181.6|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|454||||454|227|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|454||||454|204.3|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|454||||454|204.3|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|Self-pay|Self-pay|454||||454|90.8|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|TML [1980]|TML [198000]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|454||||454|63.56|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|UNICARE [2040]|UNICARE [204000]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|454||||454|0|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|WEB TPA [2115]|WEB TPA [211500]|454||||454|313.26|313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|454||||454||313.26|63.56
27400010|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|BRACE AFO CUSTOM|1|WORKER'S COMP [2125]|TML WC [212537]|454||||454|0|313.26|63.56
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AARP [1000]|AARP [100000]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AETNA [1015]|AETNA [101529]|135||||135|60.75|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AMBETTER [2930]|AMBETTER [293000]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|135||||135|67.5|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|54|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135|54|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135|63.45|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|135||||135|55.35|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|CIGNA [1260]|CIGNA PPO [126025]|135||||135|54|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|135||||135|67.5|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135|60.75|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135|60.75|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|Self-pay|Self-pay|135||||135|27|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|TML [1980]|TML [198000]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|18.9|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|UNICARE [2040]|UNICARE [204000]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135|0|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|WEB TPA [2115]|WEB TPA [211500]|135||||135|93.15|93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135||93.15|18.9
27400011|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FUNCTIONAL HAND/RESTING (WHFO)|1|WORKER'S COMP [2125]|TML WC [212537]|135||||135|0|93.15|18.9
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AARP [1000]|AARP [100000]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AETNA [1015]|AETNA [101529]|227.25||||227.25|102.26|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AMBETTER [2930]|AMBETTER [293000]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|227.25||||227.25|113.63|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|227.25||||227.25|90.9|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|227.25||||227.25|90.9|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|227.25||||227.25|106.81|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|227.25||||227.25|93.17|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|CIGNA [1260]|CIGNA PPO [126025]|227.25||||227.25|90.9|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|227.25||||227.25|113.63|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|227.25||||227.25|102.26|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|227.25||||227.25|102.26|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|Self-pay|Self-pay|227.25||||227.25|45.45|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|TML [1980]|TML [198000]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|227.25||||227.25|31.82|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|UNICARE [2040]|UNICARE [204000]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|227.25||||227.25|0|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|WEB TPA [2115]|WEB TPA [211500]|227.25||||227.25|156.8|156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|227.25||||227.25||156.8|31.82
27400016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC LMB SPLINT|1|WORKER'S COMP [2125]|TML WC [212537]|227.25||||227.25|0|156.8|31.82
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AARP [1000]|AARP [100000]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AETNA [1015]|AETNA [101529]|545.25||||545.25|245.36|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AMBETTER [2930]|AMBETTER [293000]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.25||||545.25|272.63|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.25||||545.25|218.1|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.25||||545.25|218.1|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.25||||545.25|256.27|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.25||||545.25|223.55|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|CIGNA [1260]|CIGNA PPO [126025]|545.25||||545.25|218.1|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.25||||545.25|272.63|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.25||||545.25|245.36|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.25||||545.25|245.36|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|Self-pay|Self-pay|545.25||||545.25|109.05|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|TML [1980]|TML [198000]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.25||||545.25|76.34|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|UNICARE [2040]|UNICARE [204000]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.25||||545.25|0|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|WEB TPA [2115]|WEB TPA [211500]|545.25||||545.25|376.22|376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.25||||545.25||376.22|76.34
27400020|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC STATIC ELBOW SPLINT|1|WORKER'S COMP [2125]|TML WC [212537]|545.25||||545.25|0|376.22|76.34
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AARP [1000]|AARP [100000]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AETNA [1015]|AETNA [101529]|1453.25||||1453.25|653.96|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AMBETTER [2930]|AMBETTER [293000]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1453.25||||1453.25|726.63|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1453.25||||1453.25|581.3|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1453.25||||1453.25|581.3|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1453.25||||1453.25|683.03|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1453.25||||1453.25|595.83|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|CIGNA [1260]|CIGNA PPO [126025]|1453.25||||1453.25|581.3|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1453.25||||1453.25|726.63|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1453.25||||1453.25|653.96|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1453.25||||1453.25|653.96|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|Self-pay|Self-pay|1453.25||||1453.25|290.65|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|TML [1980]|TML [198000]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1453.25||||1453.25|203.46|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|UNICARE [2040]|UNICARE [204000]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1453.25||||1453.25|0|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|WEB TPA [2115]|WEB TPA [211500]|1453.25||||1453.25|1002.74|1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1453.25||||1453.25||1002.74|203.46
27400021|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SUGARTONG SPLINT|1|WORKER'S COMP [2125]|TML WC [212537]|1453.25||||1453.25|0|1002.74|203.46
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AARP [1000]|AARP [100000]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AETNA [1015]|AETNA [101529]|499.25||||499.25|224.66|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AMBETTER [2930]|AMBETTER [293000]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|499.25||||499.25|249.63|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499.25||||499.25|199.7|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499.25||||499.25|199.7|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499.25||||499.25|234.65|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|499.25||||499.25|204.69|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|CIGNA [1260]|CIGNA PPO [126025]|499.25||||499.25|199.7|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|499.25||||499.25|249.63|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499.25||||499.25|224.66|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499.25||||499.25|224.66|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|Self-pay|Self-pay|499.25||||499.25|99.85|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|TML [1980]|TML [198000]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499.25||||499.25|69.9|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|UNICARE [2040]|UNICARE [204000]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499.25||||499.25|0|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|WEB TPA [2115]|WEB TPA [211500]|499.25||||499.25|344.48|344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499.25||||499.25||344.48|69.9
27400025|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC ULNAR GUTTER, HAND BASED|1|WORKER'S COMP [2125]|TML WC [212537]|499.25||||499.25|0|344.48|69.9
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AARP [1000]|AARP [100000]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AETNA [1015]|AETNA [101529]|862.75||||862.75|388.24|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AMBETTER [2930]|AMBETTER [293000]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|862.75||||862.75|431.38|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|862.75||||862.75|345.1|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|862.75||||862.75|345.1|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|862.75||||862.75|405.49|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|862.75||||862.75|353.73|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|CIGNA [1260]|CIGNA PPO [126025]|862.75||||862.75|345.1|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|862.75||||862.75|431.38|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|862.75||||862.75|388.24|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|862.75||||862.75|388.24|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|Self-pay|Self-pay|862.75||||862.75|172.55|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|TML [1980]|TML [198000]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|862.75||||862.75|120.79|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|UNICARE [2040]|UNICARE [204000]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|862.75||||862.75|0|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|WEB TPA [2115]|WEB TPA [211500]|862.75||||862.75|595.3|595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|862.75||||862.75||595.3|120.79
27400026|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WRIST COCK-UO SPLINT|1|WORKER'S COMP [2125]|TML WC [212537]|862.75||||862.75|0|595.3|120.79
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AARP [1000]|AARP [100000]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AETNA [1015]|AETNA [101529]|1362||||1362|612.9|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AMBETTER [2930]|AMBETTER [293000]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1362||||1362|681|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1362||||1362|544.8|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1362||||1362|544.8|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1362||||1362|640.14|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1362||||1362|558.42|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|CIGNA [1260]|CIGNA PPO [126025]|1362||||1362|544.8|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1362||||1362|681|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1362||||1362|612.9|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1362||||1362|612.9|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|Self-pay|Self-pay|1362||||1362|272.4|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|TML [1980]|TML [198000]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1362||||1362|190.68|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|UNICARE [2040]|UNICARE [204000]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1362||||1362|0|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|WEB TPA [2115]|WEB TPA [211500]|1362||||1362|939.78|939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1362||||1362||939.78|190.68
27400041|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT WRST/F-ARM RIGHT MED|1|WORKER'S COMP [2125]|TML WC [212537]|1362||||1362|0|939.78|190.68
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AARP [1000]|AARP [100000]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AETNA [1015]|AETNA [101529]|681.5||||681.5|306.68|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AMBETTER [2930]|AMBETTER [293000]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|681.5||||681.5|340.75|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|681.5||||681.5|272.6|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|681.5||||681.5|272.6|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|681.5||||681.5|320.31|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|681.5||||681.5|279.42|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|CIGNA [1260]|CIGNA PPO [126025]|681.5||||681.5|272.6|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|681.5||||681.5|340.75|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|681.5||||681.5|306.68|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|681.5||||681.5|306.68|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|Self-pay|Self-pay|681.5||||681.5|136.3|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|TML [1980]|TML [198000]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|681.5||||681.5|95.41|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|UNICARE [2040]|UNICARE [204000]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|681.5||||681.5|0|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|WEB TPA [2115]|WEB TPA [211500]|681.5||||681.5|470.24|470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|681.5||||681.5||470.24|95.41
27400070|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHFO RIGID W/O JOINTS|1|WORKER'S COMP [2125]|TML WC [212537]|681.5||||681.5|0|470.24|95.41
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AARP [1000]|AARP [100000]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AETNA [1015]|AETNA [101529]|454||||454|204.3|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AMBETTER [2930]|AMBETTER [293000]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|454||||454|227|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|454||||454|181.6|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|454||||454|181.6|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|454||||454|213.38|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|454||||454|186.14|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|CIGNA [1260]|CIGNA PPO [126025]|454||||454|181.6|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|454||||454|227|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|454||||454|204.3|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|454||||454|204.3|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|Self-pay|Self-pay|454||||454|90.8|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|TML [1980]|TML [198000]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|454||||454|63.56|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|UNICARE [2040]|UNICARE [204000]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|454||||454|0|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|WEB TPA [2115]|WEB TPA [211500]|454||||454|313.26|313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|454||||454||313.26|63.56
27400078|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC FINGER GUTTER|1|WORKER'S COMP [2125]|TML WC [212537]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AARP [1000]|AARP [100000]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AETNA [1015]|AETNA [101529]|454||||454|204.3|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AMBETTER [2930]|AMBETTER [293000]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|454||||454|227|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|454||||454|181.6|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|454||||454|181.6|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|454||||454|213.38|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|454||||454|186.14|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|CIGNA [1260]|CIGNA PPO [126025]|454||||454|181.6|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|454||||454|227|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|454||||454|204.3|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|454||||454|204.3|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|Self-pay|Self-pay|454||||454|90.8|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|TML [1980]|TML [198000]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|454||||454|63.56|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|UNICARE [2040]|UNICARE [204000]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|454||||454|0|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|WEB TPA [2115]|WEB TPA [211500]|454||||454|313.26|313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|454||||454||313.26|63.56
27400085|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FO NONTORSION JOINT CF|1|WORKER'S COMP [2125]|TML WC [212537]|454||||454|0|313.26|63.56
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AARP [1000]|AARP [100000]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AETNA [1015]|AETNA [101529]|1816||||1816|817.2|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AMBETTER [2930]|AMBETTER [293000]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1816||||1816|908|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1816||||1816|726.4|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1816||||1816|726.4|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1816||||1816|853.52|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1816||||1816|744.56|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|CIGNA [1260]|CIGNA PPO [126025]|1816||||1816|726.4|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1816||||1816|908|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1816||||1816|817.2|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1816||||1816|817.2|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|Self-pay|Self-pay|1816||||1816|363.2|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|TML [1980]|TML [198000]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1816||||1816|254.24|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|UNICARE [2040]|UNICARE [204000]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1816||||1816|0|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|WEB TPA [2115]|WEB TPA [211500]|1816||||1816|1253.04|1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1816||||1816||1253.04|254.24
27400086|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC WHO W/NONTORSION JNT(S) CF|1|WORKER'S COMP [2125]|TML WC [212537]|1816||||1816|0|1253.04|254.24
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AARP [1000]|AARP [100000]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AETNA [1015]|AETNA [101529]|236||||236|106.2|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AMBETTER [2930]|AMBETTER [293000]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|236||||236|118|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|94.4|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|94.4|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|110.92|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|236||||236|96.76|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|CIGNA [1260]|CIGNA PPO [126025]|236||||236|94.4|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|236||||236|118|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|106.2|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|106.2|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|Self-pay|Self-pay|236||||236|47.2|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|TML [1980]|TML [198000]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236|33.04|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|UNICARE [2040]|UNICARE [204000]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236|0|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|WEB TPA [2115]|WEB TPA [211500]|236||||236|162.84|162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236||162.84|33.04
27403923|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SPLINT THUMB CMC RESTRICTION|1|WORKER'S COMP [2125]|TML WC [212537]|236||||236|0|162.84|33.04
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AARP [1000]|AARP [100000]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AETNA [1015]|AETNA [101529]|719.5||||719.5|323.78|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMBETTER [2930]|AMBETTER [293000]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|719.5||||719.5|359.75|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|719.5||||719.5|287.8|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|719.5||||719.5|287.8|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|719.5||||719.5|338.17|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|719.5||||719.5|295|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA [1260]|CIGNA PPO [126025]|719.5||||719.5|287.8|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|719.5||||719.5|359.75|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|719.5||||719.5|323.78|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|719.5||||719.5|323.78|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|Self-pay|Self-pay|719.5||||719.5|143.9|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|TML [1980]|TML [198000]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|719.5||||719.5|100.73|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UNICARE [2040]|UNICARE [204000]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|719.5||||719.5|0|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WEB TPA [2115]|WEB TPA [211500]|719.5||||719.5|496.46|496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|719.5||||719.5||496.46|100.73
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WORKER'S COMP [2125]|TML WC [212537]|719.5||||719.5|0|496.46|100.73
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AARP [1000]|AARP [100000]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AETNA [1015]|AETNA [101529]|218||||218|98.1|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AMBETTER [2930]|AMBETTER [293000]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|218||||218|109|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|218||||218|87.2|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|218||||218|87.2|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|218||||218|102.46|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|218||||218|89.38|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|CIGNA [1260]|CIGNA PPO [126025]|218||||218|87.2|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|218||||218|109|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|218||||218|98.1|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|218||||218|98.1|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|Self-pay|Self-pay|218||||218|43.6|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|TML [1980]|TML [198000]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|218||||218|30.52|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|UNICARE [2040]|UNICARE [204000]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|218||||218|0|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|WEB TPA [2115]|WEB TPA [211500]|218||||218|150.42|150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|218||||218||150.42|30.52
27410024|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SHO LIFT TAPER TO METATARSAL|1|WORKER'S COMP [2125]|TML WC [212537]|218||||218|0|150.42|30.52
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AARP [1000]|AARP [100000]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA [1015]|AETNA [101529]|83.16||||83.16|37.42|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMBETTER [2930]|AMBETTER [293000]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.16||||83.16|41.58|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.16||||83.16|33.26|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.16||||83.16|33.26|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.16||||83.16|39.09|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.16||||83.16|34.1|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA [1260]|CIGNA PPO [126025]|83.16||||83.16|33.26|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.16||||83.16|41.58|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.16||||83.16|37.42|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.16||||83.16|37.42|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|Self-pay|Self-pay|83.16||||83.16|16.63|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|TML [1980]|TML [198000]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.16||||83.16|11.64|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNICARE [2040]|UNICARE [204000]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.16||||83.16|0|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WEB TPA [2115]|WEB TPA [211500]|83.16||||83.16|57.38|57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.16||||83.16||57.38|11.64
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WORKER'S COMP [2125]|TML WC [212537]|83.16||||83.16|0|57.38|11.64
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|175.08||||175.08|78.79|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|175.08||||175.08|87.54|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175.08||||175.08|70.03|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175.08||||175.08|70.03|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175.08||||175.08|82.29|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|175.08||||175.08|71.78|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|175.08||||175.08|70.03|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|175.08||||175.08|87.54|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175.08||||175.08|78.79|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175.08||||175.08|78.79|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|175.08||||175.08|35.02|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175.08||||175.08|24.51|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175.08||||175.08|0|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|175.08||||175.08|120.81|120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175.08||||175.08||120.81|24.51
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|175.08||||175.08|0|120.81|24.51
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|294.8||||294.8|132.66|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|294.8||||294.8|147.4|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|294.8||||294.8|117.92|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|294.8||||294.8|117.92|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|294.8||||294.8|138.56|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|294.8||||294.8|120.87|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|294.8||||294.8|117.92|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|294.8||||294.8|147.4|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|294.8||||294.8|132.66|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|294.8||||294.8|132.66|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|294.8||||294.8|58.96|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|294.8||||294.8|41.27|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|294.8||||294.8|0|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|294.8||||294.8|203.41|203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|294.8||||294.8||203.41|41.27
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|294.8||||294.8|0|203.41|41.27
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|408.94||||408.94|184.02|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408.94||||408.94|204.47|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.94||||408.94|163.58|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.94||||408.94|163.58|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.94||||408.94|192.2|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408.94||||408.94|167.67|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|408.94||||408.94|163.58|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408.94||||408.94|204.47|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.94||||408.94|184.02|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.94||||408.94|184.02|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|408.94||||408.94|81.79|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.94||||408.94|57.25|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.94||||408.94|0|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|408.94||||408.94|282.17|282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.94||||408.94||282.17|57.25
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|408.94||||408.94|0|282.17|57.25
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|12.1||||12.1|5.45|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.1||||12.1|6.05|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.1||||12.1|4.84|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.1||||12.1|4.84|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.1||||12.1|5.69|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.1||||12.1|4.96|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.1||||12.1|4.84|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.1||||12.1|6.05|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.1||||12.1|5.45|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.1||||12.1|5.45|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|12.1||||12.1|2.42|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.1||||12.1|1.69|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.1||||12.1|0|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.1||||12.1|8.35|8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.1||||12.1||8.35|1.69
27634|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.1||||12.1|0|8.35|1.69
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|21.96||||21.96|9.88|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.96||||21.96|10.98|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.96||||21.96|8.78|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.96||||21.96|8.78|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.96||||21.96|10.32|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.96||||21.96|9|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.96||||21.96|8.78|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.96||||21.96|10.98|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.96||||21.96|9.88|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.96||||21.96|9.88|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|21.96||||21.96|4.39|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.96||||21.96|3.07|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.96||||21.96|0|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.96||||21.96|15.15|15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.96||||21.96||15.15|3.07
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.96||||21.96|0|15.15|3.07
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AARP [1000]|AARP [100000]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AETNA [1015]|AETNA [101529]|13.2||||13.2|5.94|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|5.28|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|5.28|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.2|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|5.41|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|5.94|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|5.94|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|Self-pay|Self-pay|13.2||||13.2|2.64|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|TML [1980]|TML [198000]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|1.85|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UNICARE [2040]|UNICARE [204000]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2|0|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.2||||13.2||9.11|1.85
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2|0|9.11|1.85
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AARP [1000]|AARP [100000]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA [1015]|AETNA [101529]|142.63||||142.63|64.18|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMBETTER [2930]|AMBETTER [293000]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|142.63||||142.63|71.32|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.63||||142.63|57.05|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.63||||142.63|57.05|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.63||||142.63|67.04|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|142.63||||142.63|58.48|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA [1260]|CIGNA PPO [126025]|142.63||||142.63|57.05|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|142.63||||142.63|71.32|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.63||||142.63|64.18|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.63||||142.63|64.18|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|Self-pay|Self-pay|142.63||||142.63|28.53|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|TML [1980]|TML [198000]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.63||||142.63|19.97|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNICARE [2040]|UNICARE [204000]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.63||||142.63|0|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WEB TPA [2115]|WEB TPA [211500]|142.63||||142.63|98.41|98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.63||||142.63||98.41|19.97
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WORKER'S COMP [2125]|TML WC [212537]|142.63||||142.63|0|98.41|19.97
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.1||||9.1|4.1|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.1||||9.1|4.55|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.1||||9.1|3.64|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.1||||9.1|3.64|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.1||||9.1|4.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.1||||9.1|3.73|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.1||||9.1|3.64|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.1||||9.1|4.55|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.1||||9.1|4.1|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.1||||9.1|4.1|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|9.1||||9.1|1.82|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|TML [1980]|TML [198000]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.1||||9.1|1.27|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.1||||9.1|0|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.1||||9.1|6.28|6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.1||||9.1||6.28|1.27
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.1||||9.1|0|6.28|1.27
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1162.92||||1162.92|581.46|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1162.92||||1162.92|465.17|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1162.92||||1162.92|465.17|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1162.92||||1162.92|546.57|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1162.92||||1162.92|476.8|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1162.92||||1162.92|465.17|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1162.92||||1162.92|581.46|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1162.92||||1162.92|232.58|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1162.92||||1162.92|162.81|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1162.92||||1162.92|802.41|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1162.92||||1162.92||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1162.92||||1162.92|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.66||||594.66|297.33|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.66||||594.66|237.86|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.66||||594.66|237.86|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.66||||594.66|279.49|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.66||||594.66|243.81|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|594.66||||594.66|237.86|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.66||||594.66|297.33|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|594.66||||594.66|118.93|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.66||||594.66|83.25|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.66||||594.66|0|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|594.66||||594.66|410.32|802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.66||||594.66||802.41|83.25
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|594.66||||594.66|0|802.41|83.25
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.32||||7.32|3.29|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.32||||7.32|3.66|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.32||||7.32|2.93|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.32||||7.32|2.93|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.32||||7.32|3.44|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.32||||7.32|3|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.32||||7.32|2.93|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.32||||7.32|3.66|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.32||||7.32|3.29|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.32||||7.32|3.29|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.32||||7.32|1.46|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.32||||7.32|1.02|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.32||||7.32|0|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.32||||7.32|5.05|5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.32||||7.32||5.05|1.02
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.32||||7.32|0|5.05|1.02
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AARP [1000]|AARP [100000]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA [1015]|AETNA [101529]|554.4||||554.4|249.48|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|554.4||||554.4|277.2|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|554.4||||554.4|221.76|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|554.4||||554.4|221.76|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|554.4||||554.4|260.57|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|554.4||||554.4|227.3|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|554.4||||554.4|221.76|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|554.4||||554.4|277.2|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|554.4||||554.4|249.48|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|554.4||||554.4|249.48|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|Self-pay|Self-pay|554.4||||554.4|110.88|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|TML [1980]|TML [198000]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|554.4||||554.4|77.62|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNICARE [2040]|UNICARE [204000]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|554.4||||554.4|382.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|554.4||||554.4||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|554.4||||554.4|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AARP [1000]|AARP [100000]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA [1015]|AETNA [101529]|594||||594|267.3|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMBETTER [2930]|AMBETTER [293000]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594||||594|297|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|237.6|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|237.6|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|279.18|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594||||594|243.54|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA PPO [126025]|594||||594|237.6|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594||||594|297|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|267.3|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|267.3|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|Self-pay|Self-pay|594||||594|118.8|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|TML [1980]|TML [198000]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|83.16|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNICARE [2040]|UNICARE [204000]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WEB TPA [2115]|WEB TPA [211500]|594||||594|409.86|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TML WC [212537]|594||||594|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AARP [1000]|AARP [100000]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA [1015]|AETNA [101529]|673.2||||673.2|302.94|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMBETTER [2930]|AMBETTER [293000]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|673.2||||673.2|336.6|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|673.2||||673.2|269.28|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|673.2||||673.2|269.28|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|673.2||||673.2|316.4|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|673.2||||673.2|276.01|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA PPO [126025]|673.2||||673.2|269.28|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|673.2||||673.2|336.6|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|673.2||||673.2|302.94|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|673.2||||673.2|302.94|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|Self-pay|Self-pay|673.2||||673.2|134.64|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|TML [1980]|TML [198000]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|673.2||||673.2|94.25|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNICARE [2040]|UNICARE [204000]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|673.2||||673.2|0|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WEB TPA [2115]|WEB TPA [211500]|673.2||||673.2|464.51|464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|673.2||||673.2||464.51|77.62
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TML WC [212537]|673.2||||673.2|0|464.51|77.62
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AARP [1000]|AARP [100000]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA [1015]|AETNA [101529]|501.6||||501.6|225.72|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|501.6||||501.6|250.8|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|501.6||||501.6|200.64|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|501.6||||501.6|200.64|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|501.6||||501.6|235.75|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|501.6||||501.6|205.66|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|501.6||||501.6|200.64|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|501.6||||501.6|250.8|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|501.6||||501.6|225.72|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|501.6||||501.6|225.72|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|Self-pay|Self-pay|501.6||||501.6|100.32|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|TML [1980]|TML [198000]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|501.6||||501.6|70.22|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNICARE [2040]|UNICARE [204000]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|501.6||||501.6|0|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|501.6||||501.6|346.1|346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|501.6||||501.6||346.1|70.22
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|501.6||||501.6|0|346.1|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AARP [1000]|AARP [100000]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA [1015]|AETNA [101529]|501.6||||501.6|225.72|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|501.6||||501.6|250.8|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|501.6||||501.6|200.64|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|501.6||||501.6|200.64|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|501.6||||501.6|235.75|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|501.6||||501.6|205.66|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|501.6||||501.6|200.64|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|501.6||||501.6|250.8|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|501.6||||501.6|225.72|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|501.6||||501.6|225.72|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|Self-pay|Self-pay|501.6||||501.6|100.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|TML [1980]|TML [198000]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|501.6||||501.6|70.22|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNICARE [2040]|UNICARE [204000]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|501.6||||501.6|346.1|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|501.6||||501.6||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|501.6||||501.6|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AARP [1000]|AARP [100000]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA [1015]|AETNA [101529]|528||||528|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMBETTER [2930]|AMBETTER [293000]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528||||528|264|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528||||528|211.2|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528||||528|211.2|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528||||528|248.16|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528||||528|216.48|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA PPO [126025]|528||||528|211.2|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528||||528|264|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528||||528|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|Self-pay|Self-pay|528||||528|105.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|TML [1980]|TML [198000]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528||||528|73.92|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNICARE [2040]|UNICARE [204000]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WEB TPA [2115]|WEB TPA [211500]|528||||528|364.32|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528||||528||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TML WC [212537]|528||||528|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AARP [1000]|AARP [100000]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA [1015]|AETNA [101529]|594||||594|267.3|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMBETTER [2930]|AMBETTER [293000]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594||||594|297|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|279.18|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594||||594|243.54|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA PPO [126025]|594||||594|237.6|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594||||594|297|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|267.3|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|267.3|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|Self-pay|Self-pay|594||||594|118.8|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|TML [1980]|TML [198000]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|83.16|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNICARE [2040]|UNICARE [204000]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594|0|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WEB TPA [2115]|WEB TPA [211500]|594||||594|409.86|409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594||409.86|70.22
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TML WC [212537]|594||||594|0|409.86|70.22
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AARP [1000]|AARP [100000]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AETNA [1015]|AETNA [101529]|30.36||||30.36|13.66|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMBETTER [2930]|AMBETTER [293000]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|30.36||||30.36|15.18|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.36||||30.36|12.14|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.36||||30.36|12.14|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.36||||30.36|14.27|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|30.36||||30.36|12.45|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA [1260]|CIGNA PPO [126025]|30.36||||30.36|12.14|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|30.36||||30.36|15.18|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.36||||30.36|13.66|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.36||||30.36|13.66|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|Self-pay|Self-pay|30.36||||30.36|6.07|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|TML [1980]|TML [198000]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.36||||30.36|4.25|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UNICARE [2040]|UNICARE [204000]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WEB TPA [2115]|WEB TPA [211500]|30.36||||30.36|20.95|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.36||||30.36||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WORKER'S COMP [2125]|TML WC [212537]|30.36||||30.36|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AARP [1000]|AARP [100000]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA [1015]|AETNA [101529]|46.2||||46.2|20.79|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMBETTER [2930]|AMBETTER [293000]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.2||||46.2|23.1|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.2||||46.2|18.48|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.2||||46.2|18.48|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.2||||46.2|21.71|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.2||||46.2|18.94|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA PPO [126025]|46.2||||46.2|18.48|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.2||||46.2|23.1|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.2||||46.2|20.79|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.2||||46.2|20.79|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|Self-pay|Self-pay|46.2||||46.2|9.24|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|TML [1980]|TML [198000]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.2||||46.2|6.47|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UNICARE [2040]|UNICARE [204000]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WEB TPA [2115]|WEB TPA [211500]|46.2||||46.2|31.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.2||||46.2||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TML WC [212537]|46.2||||46.2|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AARP [1000]|AARP [100000]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AETNA [1015]|AETNA [101529]|29.7||||29.7|13.37|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AMBETTER [2930]|AMBETTER [293000]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.7||||29.7|14.85|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.7||||29.7|11.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.7||||29.7|11.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.7||||29.7|13.96|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.7||||29.7|12.18|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|CIGNA [1260]|CIGNA PPO [126025]|29.7||||29.7|11.88|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.7||||29.7|14.85|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.7||||29.7|13.37|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.7||||29.7|13.37|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|Self-pay|Self-pay|29.7||||29.7|5.94|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|TML [1980]|TML [198000]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.7||||29.7|4.16|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|UNICARE [2040]|UNICARE [204000]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|WEB TPA [2115]|WEB TPA [211500]|29.7||||29.7|20.49|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.7||||29.7||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|50 mL|WORKER'S COMP [2125]|TML WC [212537]|29.7||||29.7|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AARP [1000]|AARP [100000]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|23.76|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|26.4|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.8||||52.8|21.12|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.8||||52.8|21.12|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.8||||52.8|24.82|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|21.65|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|26.4|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|23.76|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|23.76|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|Self-pay|Self-pay|52.8||||52.8|10.56|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.8||||52.8|7.39|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8|0|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.8||||52.8||36.43|4.16
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8|0|36.43|4.16
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|6.54||||6.54|2.94|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.54||||6.54|3.27|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.54||||6.54|2.62|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.54||||6.54|2.62|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.54||||6.54|3.07|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.54||||6.54|2.68|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.54||||6.54|2.62|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.54||||6.54|3.27|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.54||||6.54|2.94|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.54||||6.54|2.94|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|6.54||||6.54|1.31|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.54||||6.54|0.92|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.54||||6.54|0|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.54||||6.54|4.51|4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.54||||6.54||4.51|0.92
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.54||||6.54|0|4.51|0.92
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|4.29||||4.29|1.93|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.29||||4.29|2.15|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.29||||4.29|1.72|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.29||||4.29|1.72|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.29||||4.29|2.02|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.29||||4.29|1.76|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.29||||4.29|1.72|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.29||||4.29|2.15|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.29||||4.29|1.93|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.29||||4.29|1.93|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|4.29||||4.29|0.86|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.29||||4.29|0.6|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.29||||4.29|0|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.29||||4.29|2.96|2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.29||||4.29||2.96|0.6
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.29||||4.29|0|2.96|0.6
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|24.48||||24.48|11.02|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.48||||24.48|12.24|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.48||||24.48|9.79|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.48||||24.48|9.79|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.48||||24.48|11.51|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.48||||24.48|10.04|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|24.48||||24.48|9.79|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.48||||24.48|12.24|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.48||||24.48|11.02|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.48||||24.48|11.02|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|24.48||||24.48|4.9|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.48||||24.48|3.43|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.48||||24.48|0|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|24.48||||24.48|16.89|16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.48||||24.48||16.89|3.43
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|24.48||||24.48|11.02|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.48||||24.48|12.24|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.48||||24.48|9.79|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.48||||24.48|9.79|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.48||||24.48|11.51|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.48||||24.48|10.04|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|24.48||||24.48|9.79|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.48||||24.48|12.24|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.48||||24.48|11.02|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.48||||24.48|11.02|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|24.48||||24.48|4.9|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.48||||24.48|3.43|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.48||||24.48|0|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|24.48||||24.48|16.89|16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.48||||24.48||16.89|3.43
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|24.48||||24.48|11.02|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.48||||24.48|12.24|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.48||||24.48|9.79|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.48||||24.48|9.79|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.48||||24.48|11.51|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.48||||24.48|10.04|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|24.48||||24.48|9.79|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.48||||24.48|12.24|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.48||||24.48|11.02|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.48||||24.48|11.02|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|24.48||||24.48|4.9|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.48||||24.48|3.43|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.48||||24.48|0|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|24.48||||24.48|16.89|16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.48||||24.48||16.89|3.43
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|24.48||||24.48|0|16.89|3.43
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AARP [1000]|AARP [100000]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AETNA [1015]|AETNA [101529]|58.41||||58.41|26.28|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AMBETTER [2930]|AMBETTER [293000]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|58.41||||58.41|29.21|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.41||||58.41|23.36|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.41||||58.41|23.36|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.41||||58.41|27.45|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|58.41||||58.41|23.95|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|CIGNA [1260]|CIGNA PPO [126025]|58.41||||58.41|23.36|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|58.41||||58.41|29.21|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.41||||58.41|26.28|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.41||||58.41|26.28|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|Self-pay|Self-pay|58.41||||58.41|11.68|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|TML [1980]|TML [198000]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.41||||58.41|8.18|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|UNICARE [2040]|UNICARE [204000]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.41||||58.41|0|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|WEB TPA [2115]|WEB TPA [211500]|58.41||||58.41|40.3|40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.41||||58.41||40.3|8.18
27890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL-PHENOLATE SODIUM MUCOSAL AEROSOL SPRAY|177 mL|WORKER'S COMP [2125]|TML WC [212537]|58.41||||58.41|0|40.3|8.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|94.12||||94.12|42.35|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|94.12||||94.12|47.06|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94.12||||94.12|37.65|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94.12||||94.12|37.65|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94.12||||94.12|44.24|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|94.12||||94.12|38.59|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|94.12||||94.12|37.65|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|94.12||||94.12|47.06|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94.12||||94.12|42.35|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94.12||||94.12|42.35|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|94.12||||94.12|18.82|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94.12||||94.12|13.18|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94.12||||94.12|0|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|94.12||||94.12|64.94|64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94.12||||94.12||64.94|13.18
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|94.12||||94.12|0|64.94|13.18
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|167.2||||167.2|75.24|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|167.2||||167.2|83.6|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|167.2||||167.2|66.88|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|167.2||||167.2|66.88|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|167.2||||167.2|78.58|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|167.2||||167.2|68.55|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|167.2||||167.2|66.88|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|167.2||||167.2|83.6|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167.2||||167.2|75.24|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167.2||||167.2|75.24|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|167.2||||167.2|33.44|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|167.2||||167.2|23.41|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167.2||||167.2|0|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|167.2||||167.2|115.37|115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|167.2||||167.2||115.37|23.41
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|167.2||||167.2|0|115.37|23.41
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|541.2||||541.2|243.54|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|541.2||||541.2|270.6|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|541.2||||541.2|216.48|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|541.2||||541.2|216.48|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|541.2||||541.2|254.36|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|541.2||||541.2|221.89|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|541.2||||541.2|216.48|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|541.2||||541.2|270.6|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|541.2||||541.2|243.54|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|541.2||||541.2|243.54|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|541.2||||541.2|108.24|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|541.2||||541.2|75.77|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|541.2||||541.2|0|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|541.2||||541.2|373.43|373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|541.2||||541.2||373.43|75.77
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|541.2||||541.2|0|373.43|75.77
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AARP [1000]|AARP [100000]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AETNA [1015]|AETNA [101529]|2.05||||2.05|0.92|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AMBETTER [2930]|AMBETTER [293000]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.05||||2.05|1.03|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.05||||2.05|0.82|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.05||||2.05|0.82|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.05||||2.05|0.96|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.05||||2.05|0.84|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA [1260]|CIGNA PPO [126025]|2.05||||2.05|0.82|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.05||||2.05|1.03|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.05||||2.05|0.92|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.05||||2.05|0.92|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|Self-pay|Self-pay|2.05||||2.05|0.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|TML [1980]|TML [198000]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.05||||2.05|0.29|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|UNICARE [2040]|UNICARE [204000]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.05||||2.05|0|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|WEB TPA [2115]|WEB TPA [211500]|2.05||||2.05|1.41|1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.05||||2.05||1.41|0.29
27991|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE|1 each|WORKER'S COMP [2125]|TML WC [212537]|2.05||||2.05|0|1.41|0.29
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|90.89||||90.89|40.9|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.89||||90.89|45.45|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.89||||90.89|36.36|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.89||||90.89|36.36|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.89||||90.89|42.72|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.89||||90.89|37.26|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|90.89||||90.89|36.36|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.89||||90.89|45.45|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.89||||90.89|40.9|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.89||||90.89|40.9|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|Self-pay|Self-pay|90.89||||90.89|18.18|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|TML [1980]|TML [198000]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.89||||90.89|12.72|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.89||||90.89|0|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|90.89||||90.89|62.71|62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.89||||90.89||62.71|12.72
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|90.89||||90.89|0|62.71|12.72
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AARP [1000]|AARP [100000]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AETNA [1015]|AETNA [101529]|18.7||||18.7|8.42|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMBETTER [2930]|AMBETTER [293000]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.7||||18.7|9.35|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.7||||18.7|7.48|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.7||||18.7|7.48|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.7||||18.7|8.79|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.7||||18.7|7.67|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA [1260]|CIGNA PPO [126025]|18.7||||18.7|7.48|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.7||||18.7|9.35|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.7||||18.7|8.42|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.7||||18.7|8.42|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|Self-pay|Self-pay|18.7||||18.7|3.74|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|TML [1980]|TML [198000]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.7||||18.7|2.62|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNICARE [2040]|UNICARE [204000]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.7||||18.7|0|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WEB TPA [2115]|WEB TPA [211500]|18.7||||18.7|12.9|12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.7||||18.7||12.9|2.62
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WORKER'S COMP [2125]|TML WC [212537]|18.7||||18.7|0|12.9|2.62
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AARP [1000]|AARP [100000]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|39.54||||39.54|17.79|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.54||||39.54|19.77|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.54||||39.54|15.82|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.54||||39.54|15.82|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.54||||39.54|18.58|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.54||||39.54|16.21|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|39.54||||39.54|15.82|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.54||||39.54|19.77|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.54||||39.54|17.79|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.54||||39.54|17.79|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|Self-pay|Self-pay|39.54||||39.54|7.91|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|TML [1980]|TML [198000]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.54||||39.54|5.54|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.54||||39.54|0|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|39.54||||39.54|27.28|27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.54||||39.54||27.28|5.54
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|39.54||||39.54|0|27.28|5.54
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|81.41||||81.41|36.63|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.41||||81.41|40.71|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.41||||81.41|32.56|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.41||||81.41|32.56|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.41||||81.41|38.26|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.41||||81.41|33.38|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|81.41||||81.41|32.56|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.41||||81.41|40.71|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.41||||81.41|36.63|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.41||||81.41|36.63|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|Self-pay|Self-pay|81.41||||81.41|16.28|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|TML [1980]|TML [198000]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.41||||81.41|11.4|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.41||||81.41|0|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|81.41||||81.41|56.17|56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.41||||81.41||56.17|11.4
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|81.41||||81.41|0|56.17|11.4
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AARP [1000]|AARP [100000]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AETNA [1015]|AETNA [101529]|526.68||||526.68|237.01|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMBETTER [2930]|AMBETTER [293000]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|526.68||||526.68|263.34|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|526.68||||526.68|210.67|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|526.68||||526.68|210.67|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|526.68||||526.68|247.54|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|526.68||||526.68|215.94|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA [1260]|CIGNA PPO [126025]|526.68||||526.68|210.67|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|526.68||||526.68|263.34|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|526.68||||526.68|237.01|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|526.68||||526.68|237.01|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|Self-pay|Self-pay|526.68||||526.68|105.34|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|TML [1980]|TML [198000]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|526.68||||526.68|73.74|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNICARE [2040]|UNICARE [204000]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|526.68||||526.68|0|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WEB TPA [2115]|WEB TPA [211500]|526.68||||526.68|363.41|363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|526.68||||526.68||363.41|73.74
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WORKER'S COMP [2125]|TML WC [212537]|526.68||||526.68|0|363.41|73.74
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|38.34||||38.34|17.25|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.34||||38.34|19.17|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.34||||38.34|15.34|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.34||||38.34|15.34|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.34||||38.34|18.02|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.34||||38.34|15.72|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|38.34||||38.34|15.34|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.34||||38.34|19.17|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.34||||38.34|17.25|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.34||||38.34|17.25|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|38.34||||38.34|7.67|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.34||||38.34|5.37|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.34||||38.34|0|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|38.34||||38.34|26.45|26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.34||||38.34||26.45|5.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|38.34||||38.34|0|26.45|5.37
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|3743||||3743|1684.35|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3743||||3743|1871.5|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3743||||3743|1497.2|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3743||||3743|1497.2|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3743||||3743|1759.21|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3743||||3743|1534.63|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|3743||||3743|1497.2|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3743||||3743|1871.5|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3743||||3743|1684.35|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3743||||3743|1684.35|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|Self-pay|Self-pay|3743||||3743|748.6|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|TML [1980]|TML [198000]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3743||||3743|524.02|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3743||||3743|0|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|3743||||3743|2582.67|2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3743||||3743||2582.67|524.02
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|3743||||3743|0|2582.67|524.02
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.53||||6.53|2.94|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.53||||6.53|3.27|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.53||||6.53|2.61|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.53||||6.53|2.61|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.53||||6.53|3.07|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.53||||6.53|2.68|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.53||||6.53|2.61|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.53||||6.53|3.27|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.53||||6.53|2.94|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.53||||6.53|2.94|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|6.53||||6.53|1.31|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.53||||6.53|0.91|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.53||||6.53|0|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.53||||6.53|4.51|4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.53||||6.53||4.51|0.91
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.53||||6.53|0|4.51|0.91
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|245.06||||245.06|110.28|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|245.06||||245.06|122.53|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245.06||||245.06|98.02|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245.06||||245.06|98.02|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245.06||||245.06|115.18|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|245.06||||245.06|100.47|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|245.06||||245.06|98.02|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|245.06||||245.06|122.53|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245.06||||245.06|110.28|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245.06||||245.06|110.28|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|245.06||||245.06|49.01|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245.06||||245.06|34.31|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245.06||||245.06|0|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|245.06||||245.06|169.09|169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245.06||||245.06||169.09|34.31
28408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|245.06||||245.06|0|169.09|34.31
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|197.48||||197.48|88.87|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|197.48||||197.48|98.74|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|197.48||||197.48|78.99|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|197.48||||197.48|78.99|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|197.48||||197.48|92.82|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|197.48||||197.48|80.97|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|197.48||||197.48|78.99|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|197.48||||197.48|98.74|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|197.48||||197.48|88.87|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|197.48||||197.48|88.87|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|Self-pay|Self-pay|197.48||||197.48|39.5|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|197.48||||197.48|27.65|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|197.48||||197.48|0|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|197.48||||197.48|136.26|136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|197.48||||197.48||136.26|27.65
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|197.48||||197.48|0|136.26|27.65
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|104.36||||104.36|46.96|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMBETTER [2930]|AMBETTER [293000]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104.36||||104.36|52.18|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104.36||||104.36|41.74|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104.36||||104.36|41.74|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104.36||||104.36|49.05|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104.36||||104.36|42.79|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|104.36||||104.36|41.74|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104.36||||104.36|52.18|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104.36||||104.36|46.96|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104.36||||104.36|46.96|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|104.36||||104.36|20.87|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TML [1980]|TML [198000]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104.36||||104.36|14.61|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNICARE [2040]|UNICARE [204000]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104.36||||104.36|0|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WEB TPA [2115]|WEB TPA [211500]|104.36||||104.36|72.01|72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104.36||||104.36||72.01|14.61
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|104.36||||104.36|0|72.01|14.61
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|122.82||||122.82|55.27|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMBETTER [2930]|AMBETTER [293000]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122.82||||122.82|61.41|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122.82||||122.82|49.13|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122.82||||122.82|49.13|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122.82||||122.82|57.73|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122.82||||122.82|50.36|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|122.82||||122.82|49.13|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122.82||||122.82|61.41|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122.82||||122.82|55.27|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122.82||||122.82|55.27|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|122.82||||122.82|24.56|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TML [1980]|TML [198000]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122.82||||122.82|17.19|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNICARE [2040]|UNICARE [204000]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122.82||||122.82|0|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WEB TPA [2115]|WEB TPA [211500]|122.82||||122.82|84.75|84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122.82||||122.82||84.75|17.19
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|122.82||||122.82|0|84.75|17.19
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AARP [1000]|AARP [100000]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AETNA [1015]|AETNA [101529]|262.55||||262.55|118.15|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMBETTER [2930]|AMBETTER [293000]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|262.55||||262.55|131.28|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|262.55||||262.55|105.02|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|262.55||||262.55|105.02|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|262.55||||262.55|123.4|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|262.55||||262.55|107.65|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA [1260]|CIGNA PPO [126025]|262.55||||262.55|105.02|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|262.55||||262.55|131.28|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|262.55||||262.55|118.15|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|262.55||||262.55|118.15|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|Self-pay|Self-pay|262.55||||262.55|52.51|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|TML [1980]|TML [198000]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|262.55||||262.55|36.76|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNICARE [2040]|UNICARE [204000]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|262.55||||262.55|0|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WEB TPA [2115]|WEB TPA [211500]|262.55||||262.55|181.16|181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|262.55||||262.55||181.16|36.76
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WORKER'S COMP [2125]|TML WC [212537]|262.55||||262.55|0|181.16|36.76
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|29.97||||29.97|13.49|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.97||||29.97|14.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.97||||29.97|11.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.97||||29.97|11.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.97||||29.97|14.09|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.97||||29.97|12.29|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|29.97||||29.97|11.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.97||||29.97|14.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.97||||29.97|13.49|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.97||||29.97|13.49|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|29.97||||29.97|5.99|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.97||||29.97|4.2|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.97||||29.97|0|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|29.97||||29.97|20.68|20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.97||||29.97||20.68|4.2
28842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE MODIFIED 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|29.97||||29.97|0|20.68|4.2
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AARP [1000]|AARP [100000]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AETNA [1015]|AETNA [101529]|401.3||||401.3|180.59|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMBETTER [2930]|AMBETTER [293000]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|401.3||||401.3|200.65|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|401.3||||401.3|160.52|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|401.3||||401.3|160.52|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|401.3||||401.3|188.61|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|401.3||||401.3|164.53|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA [1260]|CIGNA PPO [126025]|401.3||||401.3|160.52|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|401.3||||401.3|200.65|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|401.3||||401.3|180.59|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|401.3||||401.3|180.59|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|Self-pay|Self-pay|401.3||||401.3|80.26|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|TML [1980]|TML [198000]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|401.3||||401.3|56.18|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNICARE [2040]|UNICARE [204000]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|401.3||||401.3|0|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WEB TPA [2115]|WEB TPA [211500]|401.3||||401.3|276.9|276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|401.3||||401.3||276.9|56.18
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WORKER'S COMP [2125]|TML WC [212537]|401.3||||401.3|0|276.9|56.18
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|139.7||||139.7|62.87|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139.7||||139.7|69.85|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.7||||139.7|55.88|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.7||||139.7|55.88|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.7||||139.7|65.66|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139.7||||139.7|57.28|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|139.7||||139.7|55.88|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139.7||||139.7|69.85|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.7||||139.7|62.87|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.7||||139.7|62.87|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|139.7||||139.7|27.94|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.7||||139.7|19.56|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.7||||139.7|0|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|139.7||||139.7|96.39|96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.7||||139.7||96.39|19.56
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|139.7||||139.7|0|96.39|19.56
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AARP [1000]|AARP [100000]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|7537.2||||7537.2|3391.74|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7537.2||||7537.2|3768.6|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7537.2||||7537.2|3014.88|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7537.2||||7537.2|3014.88|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7537.2||||7537.2|3542.48|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7537.2||||7537.2|3090.25|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|7537.2||||7537.2|3014.88|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7537.2||||7537.2|3768.6|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7537.2||||7537.2|3391.74|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7537.2||||7537.2|3391.74|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|Self-pay|Self-pay|7537.2||||7537.2|1507.44|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|TML [1980]|TML [198000]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7537.2||||7537.2|1055.21|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UNICARE [2040]|UNICARE [204000]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7537.2||||7537.2|0|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|7537.2||||7537.2|5200.67|5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7537.2||||7537.2||5200.67|1055.21
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|7537.2||||7537.2|0|5200.67|1055.21
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|1079.82||||1079.82|485.92|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1079.82||||1079.82|539.91|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1079.82||||1079.82|431.93|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1079.82||||1079.82|431.93|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1079.82||||1079.82|507.52|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1079.82||||1079.82|442.73|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|1079.82||||1079.82|431.93|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1079.82||||1079.82|539.91|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1079.82||||1079.82|485.92|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1079.82||||1079.82|485.92|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|1079.82||||1079.82|215.96|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1079.82||||1079.82|151.17|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1079.82||||1079.82|0|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|1079.82||||1079.82|745.08|745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1079.82||||1079.82||745.08|151.17
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|1079.82||||1079.82|0|745.08|151.17
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|726||||726|326.7|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|726||||726|363|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|726||||726|290.4|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|726||||726|290.4|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|726||||726|341.22|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|726||||726|297.66|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|726||||726|290.4|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|726||||726|363|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|726||||726|326.7|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|726||||726|326.7|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|726||||726|145.2|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|726||||726|101.64|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|726||||726|0|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|726||||726|500.94|500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|726||||726||500.94|101.64
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|726||||726|0|500.94|101.64
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AARP [1000]|AARP [100000]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AETNA [1015]|AETNA [101529]|1228.4||||1228.4|552.78|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMBETTER [2930]|AMBETTER [293000]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1228.4||||1228.4|614.2|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1228.4||||1228.4|491.36|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1228.4||||1228.4|491.36|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1228.4||||1228.4|577.35|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1228.4||||1228.4|503.64|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA [1260]|CIGNA PPO [126025]|1228.4||||1228.4|491.36|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1228.4||||1228.4|614.2|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1228.4||||1228.4|552.78|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1228.4||||1228.4|552.78|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|Self-pay|Self-pay|1228.4||||1228.4|245.68|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|TML [1980]|TML [198000]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1228.4||||1228.4|171.98|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNICARE [2040]|UNICARE [204000]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1228.4||||1228.4|0|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WEB TPA [2115]|WEB TPA [211500]|1228.4||||1228.4|847.6|847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1228.4||||1228.4||847.6|171.98
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WORKER'S COMP [2125]|TML WC [212537]|1228.4||||1228.4|0|847.6|171.98
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|8.08||||8.08|3.64|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.08||||8.08|4.04|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.08||||8.08|3.23|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.08||||8.08|3.23|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.08||||8.08|3.8|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.08||||8.08|3.31|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.08||||8.08|3.23|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.08||||8.08|4.04|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.08||||8.08|3.64|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.08||||8.08|3.64|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|8.08||||8.08|1.62|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.08||||8.08|1.13|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.08||||8.08|0|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.08||||8.08|5.58|5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.08||||8.08||5.58|1.13
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.08||||8.08|0|5.58|1.13
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|20.99||||20.99|9.45|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.99||||20.99|10.5|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.99||||20.99|8.4|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.99||||20.99|8.4|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.99||||20.99|9.87|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.99||||20.99|8.61|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20.99||||20.99|8.4|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.99||||20.99|10.5|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.99||||20.99|9.45|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.99||||20.99|9.45|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|20.99||||20.99|4.2|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.99||||20.99|2.94|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.99||||20.99|0|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20.99||||20.99|14.48|14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.99||||20.99||14.48|2.94
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20.99||||20.99|0|14.48|2.94
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AARP [1000]|AARP [100000]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA [1015]|AETNA [101529]|10.46||||10.46|4.71|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMBETTER [2930]|AMBETTER [293000]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.46||||10.46|5.23|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.46||||10.46|4.18|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.46||||10.46|4.18|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.46||||10.46|4.92|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.46||||10.46|4.29|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA [1260]|CIGNA PPO [126025]|10.46||||10.46|4.18|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.46||||10.46|5.23|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.46||||10.46|4.71|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.46||||10.46|4.71|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|Self-pay|Self-pay|10.46||||10.46|2.09|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|TML [1980]|TML [198000]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.46||||10.46|1.46|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNICARE [2040]|UNICARE [204000]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.46||||10.46|0|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WEB TPA [2115]|WEB TPA [211500]|10.46||||10.46|7.22|7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.46||||10.46||7.22|1.46
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WORKER'S COMP [2125]|TML WC [212537]|10.46||||10.46|0|7.22|1.46
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|36.57||||36.57|16.46|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.57||||36.57|18.29|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.57||||36.57|14.63|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.57||||36.57|14.63|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.57||||36.57|17.19|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.57||||36.57|14.99|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|36.57||||36.57|14.63|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.57||||36.57|18.29|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.57||||36.57|16.46|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.57||||36.57|16.46|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|36.57||||36.57|7.31|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.57||||36.57|5.12|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.57||||36.57|0|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|36.57||||36.57|25.23|25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.57||||36.57||25.23|5.12
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|36.57||||36.57|0|25.23|5.12
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|12.84||||12.84|5.78|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.84||||12.84|6.42|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|5.14|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|5.14|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|6.03|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.84||||12.84|5.26|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.84||||12.84|5.14|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.84||||12.84|6.42|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|5.78|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|5.78|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|12.84||||12.84|2.57|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|1.8|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84|0|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.84||||12.84|8.86|8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|1.8
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|12.84||||12.84|5.78|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.84||||12.84|6.42|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|5.14|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|5.14|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|6.03|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.84||||12.84|5.26|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.84||||12.84|5.14|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.84||||12.84|6.42|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|5.78|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|5.78|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|12.84||||12.84|2.57|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|1.8|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84|0|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.84||||12.84|8.86|8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|1.8
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.84||||12.84|0|8.86|1.8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AARP [1000]|AARP [100000]|386.5||||386.5|13.34|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA [1015]|AETNA [101529]|386.5||||386.5|173.93|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMBETTER [2930]|AMBETTER [293000]|386.5||||386.5|10.2|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|386.5||||386.5|193.25|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386.5||||386.5|154.6|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386.5||||386.5|154.6|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386.5||||386.5|181.66|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|386.5||||386.5|158.47|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA [1260]|CIGNA PPO [126025]|386.5||||386.5|28.43|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|386.5||||386.5|13.34|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|386.5||||386.5|193.25|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386.5||||386.5|173.93|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386.5||||386.5|173.93|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386.5||||386.5|0|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|Self-pay|Self-pay|386.5||||386.5|77.3|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|TML [1980]|TML [198000]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386.5||||386.5|8.16|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386.5||||386.5|13.34|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNICARE [2040]|UNICARE [204000]|386.5||||386.5|13.34|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386.5||||386.5|13.34|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WEB TPA [2115]|WEB TPA [211500]|386.5||||386.5|266.69|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386.5||||386.5|9.71|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386.5||||386.5|19.42|266.69|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WORKER'S COMP [2125]|TML WC [212537]|386.5||||386.5|13.34|266.69|8.16
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AARP [1000]|AARP [100000]|609.12||||609.12|24.99|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA [1015]|AETNA [101529]|609.12||||609.12|274.1|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMBETTER [2930]|AMBETTER [293000]|609.12||||609.12|162.6|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.12||||609.12|304.56|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.12||||609.12|243.65|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.12||||609.12|243.65|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.12||||609.12|286.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|609.12||||609.12|249.74|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA [1260]|CIGNA PPO [126025]|609.12||||609.12|77.82|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.12||||609.12|24.99|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.12||||609.12|304.56|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.12||||609.12|274.1|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.12||||609.12|274.1|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.12||||609.12|0|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|Self-pay|Self-pay|609.12||||609.12|121.82|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|TML [1980]|TML [198000]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.12||||609.12|85.28|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.12||||609.12|24.99|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNICARE [2040]|UNICARE [204000]|609.12||||609.12|24.99|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.12||||609.12|24.99|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WEB TPA [2115]|WEB TPA [211500]|609.12||||609.12|420.29|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.12||||609.12|154.86|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.12||||609.12|309.72|420.29|24.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WORKER'S COMP [2125]|TML WC [212537]|609.12||||609.12|24.99|420.29|24.99
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AARP [1000]|AARP [100000]|185||||185|25.29|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA [1015]|AETNA [101529]|185||||185|83.25|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|185||||185|20.28|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|185||||185|92.5|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|185||||185|74|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|185||||185|74|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|185||||185|86.95|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|185||||185|75.85|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|185||||185|74|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|185||||185|25.29|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|185||||185|92.5|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|185||||185|83.25|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|185||||185|83.25|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|185||||185|0|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|Self-pay|Self-pay|185||||185|37|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|TML [1980]|TML [198000]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|185||||185|25.9|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|185||||185|25.29|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNICARE [2040]|UNICARE [204000]|185||||185|25.29|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|185||||185|25.29|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|185||||185|127.65|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|185||||185|19.31|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|185||||185|38.62|127.65|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|185||||185|25.29|127.65|19.31
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|561||||561|252.45|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|561||||561|280.5|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|561||||561|224.4|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|561||||561|224.4|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|561||||561|263.67|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|561||||561|230.01|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|561||||561|224.4|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|561||||561|280.5|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|561||||561|252.45|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|561||||561|252.45|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|Self-pay|Self-pay|561||||561|112.2|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|TML [1980]|TML [198000]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|561||||561|78.54|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|561||||561|0|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|561||||561|387.09|387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|561||||561||387.09|78.54
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|561||||561|0|387.09|78.54
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AARP [1000]|AARP [100000]|236.3||||236.3|11.63|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|236.3||||236.3|106.34|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMBETTER [2930]|AMBETTER [293000]|236.3||||236.3|8.88|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|236.3||||236.3|118.15|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236.3||||236.3|94.52|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236.3||||236.3|94.52|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236.3||||236.3|111.06|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|236.3||||236.3|96.88|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|236.3||||236.3|24.79|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|236.3||||236.3|11.63|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|236.3||||236.3|118.15|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236.3||||236.3|106.34|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236.3||||236.3|106.34|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236.3||||236.3|0|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|Self-pay|Self-pay|236.3||||236.3|47.26|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|TML [1980]|TML [198000]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236.3||||236.3|7.11|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236.3||||236.3|11.63|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNICARE [2040]|UNICARE [204000]|236.3||||236.3|11.63|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236.3||||236.3|11.63|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WEB TPA [2115]|WEB TPA [211500]|236.3||||236.3|163.05|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236.3||||236.3|8.46|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236.3||||236.3|16.92|163.05|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|236.3||||236.3|11.63|163.05|7.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AARP [1000]|AARP [100000]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA [1015]|AETNA [101529]|597.75||||597.75|268.99|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMBETTER [2930]|AMBETTER [293000]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|597.75||||597.75|298.88|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|597.75||||597.75|239.1|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|597.75||||597.75|239.1|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|597.75||||597.75|280.94|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|597.75||||597.75|245.08|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|597.75||||597.75|20.56|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|597.75||||597.75|298.88|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|597.75||||597.75|268.99|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|597.75||||597.75|268.99|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|597.75||||597.75|0|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|Self-pay|Self-pay|597.75||||597.75|119.55|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|TML [1980]|TML [198000]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNICARE [2040]|UNICARE [204000]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WEB TPA [2115]|WEB TPA [211500]|597.75||||597.75|412.45|412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|597.75||||597.75||412.45|20.56
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|597.75||||597.75||412.45|20.56
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AARP [1000]|AARP [100000]|347.11||||347.11|14.53|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|347.11||||347.11|156.2|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMBETTER [2930]|AMBETTER [293000]|347.11||||347.11|11.09|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|347.11||||347.11|173.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347.11||||347.11|138.84|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347.11||||347.11|138.84|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347.11||||347.11|163.14|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|347.11||||347.11|142.32|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|347.11||||347.11|30.95|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|347.11||||347.11|14.53|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|347.11||||347.11|173.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347.11||||347.11|156.2|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347.11||||347.11|156.2|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347.11||||347.11|0|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|Self-pay|Self-pay|347.11||||347.11|69.42|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|TML [1980]|TML [198000]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347.11||||347.11|8.87|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347.11||||347.11|14.53|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNICARE [2040]|UNICARE [204000]|347.11||||347.11|14.53|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347.11||||347.11|14.53|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WEB TPA [2115]|WEB TPA [211500]|347.11||||347.11|239.51|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347.11||||347.11|10.56|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347.11||||347.11|21.12|239.51|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|347.11||||347.11|14.53|239.51|8.87
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AARP [1000]|AARP [100000]|534||||534|18.42|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA [1015]|AETNA [101529]|534||||534|240.3|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMBETTER [2930]|AMBETTER [293000]|534||||534|14.06|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|534||||534|267|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|534||||534|213.6|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|534||||534|213.6|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|534||||534|250.98|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|534||||534|218.94|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA [1260]|CIGNA PPO [126025]|534||||534|38.13|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|534||||534|18.42|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|534||||534|267|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|534||||534|240.3|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|534||||534|240.3|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|534||||534|0|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|Self-pay|Self-pay|534||||534|106.8|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|TML [1980]|TML [198000]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|534||||534|11.25|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|534||||534|18.42|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNICARE [2040]|UNICARE [204000]|534||||534|18.42|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|534||||534|18.42|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WEB TPA [2115]|WEB TPA [211500]|534||||534|368.46|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|534||||534|13.39|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|534||||534|26.78|368.46|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WORKER'S COMP [2125]|TML WC [212537]|534||||534|18.42|368.46|11.25
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AARP [1000]|AARP [100000]|347.11||||347.11|11.94|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|347.11||||347.11|156.2|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMBETTER [2930]|AMBETTER [293000]|347.11||||347.11|9.11|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|347.11||||347.11|173.56|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347.11||||347.11|138.84|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347.11||||347.11|138.84|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347.11||||347.11|163.14|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|347.11||||347.11|142.32|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|347.11||||347.11|25.45|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|347.11||||347.11|11.94|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|347.11||||347.11|173.56|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347.11||||347.11|156.2|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347.11||||347.11|156.2|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347.11||||347.11|0|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|Self-pay|Self-pay|347.11||||347.11|69.42|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|TML [1980]|TML [198000]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347.11||||347.11|7.29|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347.11||||347.11|11.94|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNICARE [2040]|UNICARE [204000]|347.11||||347.11|11.94|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347.11||||347.11|11.94|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WEB TPA [2115]|WEB TPA [211500]|347.11||||347.11|239.51|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347.11||||347.11|8.68|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347.11||||347.11|17.36|239.51|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|347.11||||347.11|11.94|239.51|7.29
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AARP [1000]|AARP [100000]|2095.08||||2095.08|65.47|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA [1015]|AETNA [101529]|2095.08||||2095.08|942.79|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMBETTER [2930]|AMBETTER [293000]|2095.08||||2095.08|50.01|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2095.08||||2095.08|1047.54|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2095.08||||2095.08|838.03|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2095.08||||2095.08|838.03|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2095.08||||2095.08|984.69|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2095.08||||2095.08|858.98|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|2095.08||||2095.08|136.84|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2095.08||||2095.08|65.47|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2095.08||||2095.08|1047.54|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2095.08||||2095.08|942.79|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2095.08||||2095.08|942.79|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2095.08||||2095.08|0|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|Self-pay|Self-pay|2095.08||||2095.08|419.02|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|TML [1980]|TML [198000]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2095.08||||2095.08|40.01|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2095.08||||2095.08|65.47|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNICARE [2040]|UNICARE [204000]|2095.08||||2095.08|65.47|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2095.08||||2095.08|65.47|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WEB TPA [2115]|WEB TPA [211500]|2095.08||||2095.08|1445.61|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2095.08||||2095.08|47.63|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2095.08||||2095.08|95.26|1445.61|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|2095.08||||2095.08|65.47|1445.61|40.01
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AARP [1000]|AARP [100000]|326.76||||326.76|11.23|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|326.76||||326.76|147.04|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMBETTER [2930]|AMBETTER [293000]|326.76||||326.76|8.58|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326.76||||326.76|163.38|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326.76||||326.76|130.7|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326.76||||326.76|130.7|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326.76||||326.76|153.58|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326.76||||326.76|133.97|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|326.76||||326.76|23.93|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326.76||||326.76|11.23|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326.76||||326.76|163.38|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326.76||||326.76|147.04|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326.76||||326.76|147.04|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326.76||||326.76|0|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|Self-pay|Self-pay|326.76||||326.76|65.35|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|TML [1980]|TML [198000]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326.76||||326.76|6.86|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326.76||||326.76|11.23|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNICARE [2040]|UNICARE [204000]|326.76||||326.76|11.23|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326.76||||326.76|11.23|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WEB TPA [2115]|WEB TPA [211500]|326.76||||326.76|225.46|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326.76||||326.76|8.17|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326.76||||326.76|16.34|225.46|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|326.76||||326.76|11.23|225.46|6.86
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AARP [1000]|AARP [100000]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA [1015]|AETNA [101529]|471||||471|211.95|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMBETTER [2930]|AMBETTER [293000]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|471||||471|235.5|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|471||||471|188.4|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|471||||471|188.4|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|471||||471|221.37|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|471||||471|193.11|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA [1260]|CIGNA PPO [126025]|471||||471|44.19|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|471||||471|235.5|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|471||||471|211.95|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|471||||471|211.95|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|471||||471|0|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|Self-pay|Self-pay|471||||471|94.2|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|TML [1980]|TML [198000]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNICARE [2040]|UNICARE [204000]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WEB TPA [2115]|WEB TPA [211500]|471||||471|324.99|324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|471||||471||324.99|44.19
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WORKER'S COMP [2125]|TML WC [212537]|471||||471||324.99|44.19
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AARP [1000]|AARP [100000]|580.25||||580.25|20.02|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AETNA [1015]|AETNA [101529]|580.25||||580.25|261.11|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AMBETTER [2930]|AMBETTER [293000]|580.25||||580.25|15.3|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.25||||580.25|290.13|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580.25||||580.25|232.1|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580.25||||580.25|232.1|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580.25||||580.25|272.72|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.25||||580.25|237.9|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA [1260]|CIGNA PPO [126025]|580.25||||580.25|42.7|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.25||||580.25|20.02|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.25||||580.25|290.13|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.25||||580.25|261.11|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.25||||580.25|261.11|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.25||||580.25|0|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|Self-pay|Self-pay|580.25||||580.25|116.05|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|TML [1980]|TML [198000]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580.25||||580.25|12.24|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.25||||580.25|20.02|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UNICARE [2040]|UNICARE [204000]|580.25||||580.25|20.02|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.25||||580.25|20.02|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WEB TPA [2115]|WEB TPA [211500]|580.25||||580.25|400.37|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.25||||580.25|14.57|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580.25||||580.25|29.14|400.37|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WORKER'S COMP [2125]|TML WC [212537]|580.25||||580.25|20.02|400.37|12.24
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AARP [1000]|AARP [100000]|621||||621|24.81|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA [1015]|AETNA [101529]|621||||621|279.45|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMBETTER [2930]|AMBETTER [293000]|621||||621|18.95|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|621||||621|310.5|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|621||||621|248.4|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|621||||621|248.4|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|621||||621|291.87|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|621||||621|254.61|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA [1260]|CIGNA PPO [126025]|621||||621|52.89|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|621||||621|24.81|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|621||||621|310.5|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|621||||621|279.45|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|621||||621|279.45|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|621||||621|0|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|Self-pay|Self-pay|621||||621|124.2|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|TML [1980]|TML [198000]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|621||||621|15.16|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|621||||621|24.81|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNICARE [2040]|UNICARE [204000]|621||||621|24.81|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|621||||621|24.81|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WEB TPA [2115]|WEB TPA [211500]|621||||621|428.49|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|621||||621|18.05|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|621||||621|36.1|428.49|15.16
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WORKER'S COMP [2125]|TML WC [212537]|621||||621|24.81|428.49|15.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AARP [1000]|AARP [100000]|582||||582|18.25|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA [1015]|AETNA [101529]|582||||582|261.9|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|582||||582|13.94|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|582||||582|291|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|582||||582|232.8|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|582||||582|232.8|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|582||||582|273.54|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|582||||582|238.62|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|582||||582|38.93|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|582||||582|18.25|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|582||||582|291|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|582||||582|261.9|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|582||||582|261.9|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|582||||582|0|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|Self-pay|Self-pay|582||||582|116.4|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|TML [1980]|TML [198000]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|582||||582|11.16|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|582||||582|18.25|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNICARE [2040]|UNICARE [204000]|582||||582|18.25|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|582||||582|18.25|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|582||||582|401.58|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|582||||582|13.28|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|582||||582|26.56|401.58|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|582||||582|18.25|401.58|11.16
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AARP [1000]|AARP [100000]|424||||424|18.63|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA [1015]|AETNA [101529]|424||||424|190.8|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|424||||424|14.22|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|424||||424|212|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|424||||424|169.6|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|424||||424|169.6|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|424||||424|199.28|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|424||||424|173.84|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|424||||424|39.72|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|424||||424|18.63|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|424||||424|212|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|424||||424|190.8|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|424||||424|190.8|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|424||||424|0|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|Self-pay|Self-pay|424||||424|84.8|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|TML [1980]|TML [198000]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|424||||424|11.37|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|424||||424|18.63|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNICARE [2040]|UNICARE [204000]|424||||424|18.63|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|424||||424|18.63|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|424||||424|292.56|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|424||||424|13.54|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|424||||424|27.08|292.56|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|424||||424|18.63|292.56|11.37
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AARP [1000]|AARP [100000]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA [1015]|AETNA [101529]|513||||513|230.85|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMBETTER [2930]|AMBETTER [293000]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|513||||513|256.5|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|513||||513|205.2|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|513||||513|205.2|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|513||||513|241.11|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|513||||513|210.33|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA [1260]|CIGNA PPO [126025]|513||||513|48.03|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|513||||513|256.5|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|513||||513|230.85|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|513||||513|230.85|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|513||||513|0|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|Self-pay|Self-pay|513||||513|102.6|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|TML [1980]|TML [198000]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNICARE [2040]|UNICARE [204000]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WEB TPA [2115]|WEB TPA [211500]|513||||513|353.97|353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|513||||513||353.97|48.03
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WORKER'S COMP [2125]|TML WC [212537]|513||||513||353.97|48.03
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AARP [1000]|AARP [100000]|586.08||||586.08|18.09|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AETNA [1015]|AETNA [101529]|586.08||||586.08|263.74|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AMBETTER [2930]|AMBETTER [293000]|586.08||||586.08|13.91|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|586.08||||586.08|293.04|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|586.08||||586.08|234.43|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|586.08||||586.08|234.43|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|586.08||||586.08|275.46|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|586.08||||586.08|240.29|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA [1260]|CIGNA PPO [126025]|586.08||||586.08|38.86|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|586.08||||586.08|18.09|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|586.08||||586.08|293.04|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|586.08||||586.08|263.74|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|586.08||||586.08|263.74|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|586.08||||586.08|0|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|Self-pay|Self-pay|586.08||||586.08|117.22|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|TML [1980]|TML [198000]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|586.08||||586.08|11.13|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|586.08||||586.08|18.09|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UNICARE [2040]|UNICARE [204000]|586.08||||586.08|18.09|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|586.08||||586.08|18.09|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WEB TPA [2115]|WEB TPA [211500]|586.08||||586.08|404.4|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|586.08||||586.08|13.25|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|586.08||||586.08|26.5|404.4|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WORKER'S COMP [2125]|TML WC [212537]|586.08||||586.08|18.09|404.4|11.13
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AARP [1000]|AARP [100000]|207||||207|9.09|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AETNA [1015]|AETNA [101529]|207||||207|93.15|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AMBETTER [2930]|AMBETTER [293000]|207||||207|6.94|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|207||||207|103.5|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|207||||207|82.8|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|207||||207|82.8|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|207||||207|97.29|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|207||||207|84.87|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA [1260]|CIGNA PPO [126025]|207||||207|19.4|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|207||||207|9.09|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|207||||207|103.5|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|207||||207|93.15|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|207||||207|93.15|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|207||||207|0|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|Self-pay|Self-pay|207||||207|41.4|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|TML [1980]|TML [198000]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|207||||207|5.55|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|207||||207|9.09|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UNICARE [2040]|UNICARE [204000]|207||||207|9.09|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|207||||207|9.09|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WEB TPA [2115]|WEB TPA [211500]|207||||207|142.83|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|207||||207|6.61|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|207||||207|13.22|142.83|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WORKER'S COMP [2125]|TML WC [212537]|207||||207|9.09|142.83|5.55
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AARP [1000]|AARP [100000]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA [1015]|AETNA [101529]|456.5||||456.5|205.43|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMBETTER [2930]|AMBETTER [293000]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|456.5||||456.5|228.25|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|456.5||||456.5|182.6|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|456.5||||456.5|182.6|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|456.5||||456.5|214.56|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|456.5||||456.5|187.17|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA [1260]|CIGNA PPO [126025]|456.5||||456.5|33.56|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|456.5||||456.5|228.25|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|456.5||||456.5|205.43|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|456.5||||456.5|205.43|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|456.5||||456.5|0|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|Self-pay|Self-pay|456.5||||456.5|91.3|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|TML [1980]|TML [198000]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNICARE [2040]|UNICARE [204000]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WEB TPA [2115]|WEB TPA [211500]|456.5||||456.5|314.99|314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|456.5||||456.5||314.99|33.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WORKER'S COMP [2125]|TML WC [212537]|456.5||||456.5||314.99|33.56
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AARP [1000]|AARP [100000]|415||||415|18.22|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA [1015]|AETNA [101529]|415||||415|186.75|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMBETTER [2930]|AMBETTER [293000]|415||||415|13.91|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|415||||415|207.5|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|415||||415|166|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|415||||415|166|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|415||||415|195.05|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|415||||415|170.15|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA [1260]|CIGNA PPO [126025]|415||||415|38.86|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|415||||415|18.22|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|415||||415|207.5|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|415||||415|186.75|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|415||||415|186.75|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|415||||415|0|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|Self-pay|Self-pay|415||||415|83|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|TML [1980]|TML [198000]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|415||||415|11.13|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|415||||415|18.22|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNICARE [2040]|UNICARE [204000]|415||||415|18.22|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|415||||415|18.22|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WEB TPA [2115]|WEB TPA [211500]|415||||415|286.35|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|415||||415|13.25|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|415||||415|26.5|286.35|11.13
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WORKER'S COMP [2125]|TML WC [212537]|415||||415|18.22|286.35|11.13
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AARP [1000]|AARP [100000]|545.75||||545.75|18.87|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AETNA [1015]|AETNA [101529]|545.75||||545.75|245.59|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AMBETTER [2930]|AMBETTER [293000]|545.75||||545.75|14.42|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.75||||545.75|272.88|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.75||||545.75|218.3|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.75||||545.75|218.3|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.75||||545.75|256.5|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.75||||545.75|223.76|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA [1260]|CIGNA PPO [126025]|545.75||||545.75|40.25|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.75||||545.75|18.87|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.75||||545.75|272.88|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.75||||545.75|245.59|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.75||||545.75|245.59|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.75||||545.75|0|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|Self-pay|Self-pay|545.75||||545.75|109.15|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|TML [1980]|TML [198000]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.75||||545.75|11.53|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.75||||545.75|18.87|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UNICARE [2040]|UNICARE [204000]|545.75||||545.75|18.87|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.75||||545.75|18.87|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WEB TPA [2115]|WEB TPA [211500]|545.75||||545.75|376.57|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.75||||545.75|13.73|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.75||||545.75|27.46|376.57|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WORKER'S COMP [2125]|TML WC [212537]|545.75||||545.75|18.87|376.57|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AARP [1000]|AARP [100000]|546.75||||546.75|18.87|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA [1015]|AETNA [101529]|546.75||||546.75|246.04|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMBETTER [2930]|AMBETTER [293000]|546.75||||546.75|14.42|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|546.75||||546.75|273.38|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546.75||||546.75|218.7|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546.75||||546.75|218.7|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546.75||||546.75|256.97|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|546.75||||546.75|224.17|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA [1260]|CIGNA PPO [126025]|546.75||||546.75|40.25|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|546.75||||546.75|18.87|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|546.75||||546.75|273.38|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546.75||||546.75|246.04|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546.75||||546.75|246.04|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546.75||||546.75|0|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|Self-pay|Self-pay|546.75||||546.75|109.35|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|TML [1980]|TML [198000]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546.75||||546.75|11.53|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546.75||||546.75|18.87|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNICARE [2040]|UNICARE [204000]|546.75||||546.75|18.87|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546.75||||546.75|18.87|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WEB TPA [2115]|WEB TPA [211500]|546.75||||546.75|377.26|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546.75||||546.75|13.73|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546.75||||546.75|27.46|377.26|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WORKER'S COMP [2125]|TML WC [212537]|546.75||||546.75|18.87|377.26|11.53
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AARP [1000]|AARP [100000]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA [1015]|AETNA [101529]|504||||504|226.8|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMBETTER [2930]|AMBETTER [293000]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|504||||504|252|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|504||||504|201.6|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|504||||504|201.6|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|504||||504|236.88|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|504||||504|206.64|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA [1260]|CIGNA PPO [126025]|504||||504|47.23|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|504||||504|252|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|504||||504|226.8|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|504||||504|226.8|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|504||||504|0|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|Self-pay|Self-pay|504||||504|100.8|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|TML [1980]|TML [198000]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNICARE [2040]|UNICARE [204000]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WEB TPA [2115]|WEB TPA [211500]|504||||504|347.76|347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|504||||504||347.76|47.23
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WORKER'S COMP [2125]|TML WC [212537]|504||||504||347.76|47.23
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AARP [1000]|AARP [100000]|424||||424|18.63|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA [1015]|AETNA [101529]|424||||424|190.8|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMBETTER [2930]|AMBETTER [293000]|424||||424|14.22|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|424||||424|212|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|424||||424|169.6|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|424||||424|169.6|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|424||||424|199.28|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|424||||424|173.84|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA [1260]|CIGNA PPO [126025]|424||||424|39.72|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|424||||424|18.63|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|424||||424|212|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|424||||424|190.8|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|424||||424|190.8|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|424||||424|0|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|Self-pay|Self-pay|424||||424|84.8|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|TML [1980]|TML [198000]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|424||||424|11.37|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|424||||424|18.63|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNICARE [2040]|UNICARE [204000]|424||||424|18.63|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|424||||424|18.63|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WEB TPA [2115]|WEB TPA [211500]|424||||424|292.56|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|424||||424|13.54|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|424||||424|27.08|292.56|11.37
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WORKER'S COMP [2125]|TML WC [212537]|424||||424|18.63|292.56|11.37
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AARP [1000]|AARP [100000]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA [1015]|AETNA [101529]|785.88||||785.88|353.65|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMBETTER [2930]|AMBETTER [293000]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|785.88||||785.88|392.94|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|785.88||||785.88|314.35|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|785.88||||785.88|314.35|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|785.88||||785.88|369.36|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|785.88||||785.88|322.21|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA [1260]|CIGNA PPO [126025]|785.88||||785.88|40.15|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|785.88||||785.88|392.94|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785.88||||785.88|353.65|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785.88||||785.88|353.65|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785.88||||785.88|0|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|Self-pay|Self-pay|785.88||||785.88|157.18|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|TML [1980]|TML [198000]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNICARE [2040]|UNICARE [204000]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WEB TPA [2115]|WEB TPA [211500]|785.88||||785.88|542.26|542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|785.88||||785.88||542.26|40.15
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WORKER'S COMP [2125]|TML WC [212537]|785.88||||785.88||542.26|40.15
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AARP [1000]|AARP [100000]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AETNA [1015]|AETNA [101529]|715.75||||715.75|322.09|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AMBETTER [2930]|AMBETTER [293000]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|715.75||||715.75|357.88|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|715.75||||715.75|286.3|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|715.75||||715.75|286.3|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|715.75||||715.75|336.4|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|715.75||||715.75|293.46|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA [1260]|CIGNA PPO [126025]|715.75||||715.75|127.93|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|715.75||||715.75|357.88|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|715.75||||715.75|322.09|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|715.75||||715.75|322.09|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|715.75||||715.75|0|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|Self-pay|Self-pay|715.75||||715.75|143.15|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|TML [1980]|TML [198000]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UNICARE [2040]|UNICARE [204000]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WEB TPA [2115]|WEB TPA [211500]|715.75||||715.75|493.87|493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|715.75||||715.75||493.87|127.93
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WORKER'S COMP [2125]|TML WC [212537]|715.75||||715.75||493.87|127.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AARP [1000]|AARP [100000]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA [1015]|AETNA [101529]|281.25||||281.25|126.56|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMBETTER [2930]|AMBETTER [293000]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|281.25||||281.25|140.63|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|281.25||||281.25|112.5|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|281.25||||281.25|112.5|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|281.25||||281.25|132.19|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|281.25||||281.25|115.31|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA [1260]|CIGNA PPO [126025]|281.25||||281.25|23.93|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|281.25||||281.25|140.63|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|281.25||||281.25|126.56|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|281.25||||281.25|126.56|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|281.25||||281.25|0|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|Self-pay|Self-pay|281.25||||281.25|56.25|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|TML [1980]|TML [198000]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNICARE [2040]|UNICARE [204000]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WEB TPA [2115]|WEB TPA [211500]|281.25||||281.25|194.06|194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|281.25||||281.25||194.06|23.93
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WORKER'S COMP [2125]|TML WC [212537]|281.25||||281.25||194.06|23.93
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AARP [1000]|AARP [100000]|1382||||1382|53.1|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA [1015]|AETNA [101529]|1382||||1382|621.9|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMBETTER [2930]|AMBETTER [293000]|1382||||1382|40.55|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1382||||1382|691|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1382||||1382|552.8|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1382||||1382|552.8|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1382||||1382|649.54|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1382||||1382|566.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA [1260]|CIGNA PPO [126025]|1382||||1382|113.2|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1382||||1382|53.1|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1382||||1382|691|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1382||||1382|621.9|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1382||||1382|621.9|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1382||||1382|0|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|Self-pay|Self-pay|1382||||1382|276.4|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|TML [1980]|TML [198000]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1382||||1382|32.44|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1382||||1382|53.1|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNICARE [2040]|UNICARE [204000]|1382||||1382|53.1|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1382||||1382|53.1|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WEB TPA [2115]|WEB TPA [211500]|1382||||1382|953.58|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1382||||1382|38.62|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1382||||1382|77.24|953.58|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WORKER'S COMP [2125]|TML WC [212537]|1382||||1382|53.1|953.58|32.44
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AARP [1000]|AARP [100000]|100||||100|6.8|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA [1015]|AETNA [101529]|100||||100|45|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMBETTER [2930]|AMBETTER [293000]|100||||100|5.2|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|100||||100|50|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|100||||100|40|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|100||||100|40|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|100||||100|47|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|100||||100|41|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA [1260]|CIGNA PPO [126025]|100||||100|14.5|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|100||||100|6.8|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|100||||100|50|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|100||||100|45|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|100||||100|45|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|100||||100|0|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|Self-pay|Self-pay|100||||100|20|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|TML [1980]|TML [198000]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|100||||100|4.16|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|100||||100|6.8|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNICARE [2040]|UNICARE [204000]|100||||100|6.8|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|100||||100|6.8|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WEB TPA [2115]|WEB TPA [211500]|100||||100|69|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|100||||100|4.95|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|100||||100|9.9|69|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WORKER'S COMP [2125]|TML WC [212537]|100||||100|6.8|69|4.16
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AARP [1000]|AARP [100000]|104||||104|7.11|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA [1015]|AETNA [101529]|104||||104|46.8|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|8.17|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|52|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|41.6|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|41.6|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|48.88|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|42.64|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|15.16|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104|7.11|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|52|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|46.8|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|46.8|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|0|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|Self-pay|Self-pay|104||||104|20.8|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|TML [1980]|TML [198000]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|6.54|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|7.11|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNICARE [2040]|UNICARE [204000]|104||||104|7.11|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|7.11|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|7.78|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|15.56|71.76|6.54
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104|7.11|71.76|6.54
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AARP [1000]|AARP [100000]|386.5||||386.5|13.34|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA [1015]|AETNA [101529]|386.5||||386.5|173.93|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMBETTER [2930]|AMBETTER [293000]|386.5||||386.5|10.2|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|386.5||||386.5|193.25|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386.5||||386.5|154.6|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386.5||||386.5|154.6|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386.5||||386.5|181.66|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|386.5||||386.5|158.47|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA [1260]|CIGNA PPO [126025]|386.5||||386.5|28.43|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|386.5||||386.5|13.34|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|386.5||||386.5|193.25|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386.5||||386.5|173.93|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386.5||||386.5|173.93|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386.5||||386.5|0|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|Self-pay|Self-pay|386.5||||386.5|77.3|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|TML [1980]|TML [198000]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386.5||||386.5|8.16|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386.5||||386.5|13.34|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNICARE [2040]|UNICARE [204000]|386.5||||386.5|13.34|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386.5||||386.5|13.34|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WEB TPA [2115]|WEB TPA [211500]|386.5||||386.5|266.69|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386.5||||386.5|9.71|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386.5||||386.5|19.42|266.69|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WORKER'S COMP [2125]|TML WC [212537]|386.5||||386.5|13.34|266.69|8.16
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AARP [1000]|AARP [100000]|774||||774|56.02|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA [1015]|AETNA [101529]|774||||774|348.3|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMBETTER [2930]|AMBETTER [293000]|774||||774|42.79|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|774||||774|387|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|774||||774|309.6|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|774||||774|309.6|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|774||||774|363.78|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|774||||774|317.34|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA [1260]|CIGNA PPO [126025]|774||||774|119.42|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|774||||774|56.02|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|774||||774|387|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|774||||774|348.3|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|774||||774|348.3|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|774||||774|0|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|Self-pay|Self-pay|774||||774|154.8|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|TML [1980]|TML [198000]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|774||||774|34.23|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|774||||774|56.02|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNICARE [2040]|UNICARE [204000]|774||||774|56.02|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|774||||774|56.02|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WEB TPA [2115]|WEB TPA [211500]|774||||774|534.06|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|774||||774|40.75|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|774||||774|81.5|534.06|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WORKER'S COMP [2125]|TML WC [212537]|774||||774|56.02|534.06|34.23
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AARP [1000]|AARP [100000]|372||||372|23.06|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|372||||372|167.4|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMBETTER [2930]|AMBETTER [293000]|372||||372|17.61|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|372||||372|186|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|372||||372|148.8|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|372||||372|148.8|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|372||||372|174.84|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|372||||372|152.52|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|372||||372|49.15|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|372||||372|23.06|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|372||||372|186|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|372||||372|167.4|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|372||||372|167.4|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|372||||372|0|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|Self-pay|Self-pay|372||||372|74.4|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|TML [1980]|TML [198000]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|372||||372|14.09|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|372||||372|23.06|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNICARE [2040]|UNICARE [204000]|372||||372|23.06|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|372||||372|23.06|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WEB TPA [2115]|WEB TPA [211500]|372||||372|256.68|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|372||||372|16.77|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|372||||372|33.54|256.68|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|372||||372|23.06|256.68|14.09
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AARP [1000]|AARP [100000]|569.5||||569.5|20.03|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA [1015]|AETNA [101529]|569.5||||569.5|256.28|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMBETTER [2930]|AMBETTER [293000]|569.5||||569.5|15.3|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|569.5||||569.5|284.75|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|569.5||||569.5|227.8|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|569.5||||569.5|227.8|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|569.5||||569.5|267.67|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|569.5||||569.5|233.5|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA [1260]|CIGNA PPO [126025]|569.5||||569.5|42.7|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|569.5||||569.5|20.03|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|569.5||||569.5|284.75|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|569.5||||569.5|256.28|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|569.5||||569.5|256.28|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|569.5||||569.5|0|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|Self-pay|Self-pay|569.5||||569.5|113.9|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|TML [1980]|TML [198000]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|569.5||||569.5|12.24|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|569.5||||569.5|20.03|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNICARE [2040]|UNICARE [204000]|569.5||||569.5|20.03|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|569.5||||569.5|20.03|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WEB TPA [2115]|WEB TPA [211500]|569.5||||569.5|392.96|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|569.5||||569.5|14.57|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|569.5||||569.5|29.14|392.96|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WORKER'S COMP [2125]|TML WC [212537]|569.5||||569.5|20.03|392.96|12.24
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AARP [1000]|AARP [100000]|131||||131|8.91|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA [1015]|AETNA [101529]|131||||131|58.95|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMBETTER [2930]|AMBETTER [293000]|131||||131|6.8|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131||||131|65.5|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131||||131|52.4|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131||||131|52.4|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131||||131|61.57|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131||||131|53.71|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA [1260]|CIGNA PPO [126025]|131||||131|19|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131||||131|8.91|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131||||131|65.5|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131||||131|58.95|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131||||131|58.95|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131||||131|0|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|Self-pay|Self-pay|131||||131|26.2|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|TML [1980]|TML [198000]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131||||131|5.44|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131||||131|8.91|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNICARE [2040]|UNICARE [204000]|131||||131|8.91|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131||||131|8.91|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WEB TPA [2115]|WEB TPA [211500]|131||||131|90.39|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131||||131|6.48|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131||||131|12.96|90.39|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WORKER'S COMP [2125]|TML WC [212537]|131||||131|8.91|90.39|5.44
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AARP [1000]|AARP [100000]|581.5||||581.5|20.07|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA [1015]|AETNA [101529]|581.5||||581.5|261.68|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMBETTER [2930]|AMBETTER [293000]|581.5||||581.5|15.33|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|581.5||||581.5|290.75|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|581.5||||581.5|232.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|581.5||||581.5|232.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|581.5||||581.5|273.31|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|581.5||||581.5|238.42|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA [1260]|CIGNA PPO [126025]|581.5||||581.5|42.8|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|581.5||||581.5|20.07|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|581.5||||581.5|290.75|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|581.5||||581.5|261.68|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|581.5||||581.5|261.68|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|581.5||||581.5|0|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|Self-pay|Self-pay|581.5||||581.5|116.3|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|TML [1980]|TML [198000]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|581.5||||581.5|12.26|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|581.5||||581.5|20.07|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNICARE [2040]|UNICARE [204000]|581.5||||581.5|20.07|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|581.5||||581.5|20.07|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WEB TPA [2115]|WEB TPA [211500]|581.5||||581.5|401.24|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|581.5||||581.5|14.6|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|581.5||||581.5|29.2|401.24|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WORKER'S COMP [2125]|TML WC [212537]|581.5||||581.5|20.07|401.24|12.26
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AARP [1000]|AARP [100000]|644.5||||644.5|22.24|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AETNA [1015]|AETNA [101529]|644.5||||644.5|290.03|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AMBETTER [2930]|AMBETTER [293000]|644.5||||644.5|16.99|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|644.5||||644.5|322.25|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|644.5||||644.5|257.8|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|644.5||||644.5|257.8|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|644.5||||644.5|302.92|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|644.5||||644.5|264.25|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA [1260]|CIGNA PPO [126025]|644.5||||644.5|47.43|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|644.5||||644.5|22.24|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|644.5||||644.5|322.25|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|644.5||||644.5|290.03|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|644.5||||644.5|290.03|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|644.5||||644.5|0|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|Self-pay|Self-pay|644.5||||644.5|128.9|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|TML [1980]|TML [198000]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|644.5||||644.5|13.59|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|644.5||||644.5|22.24|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UNICARE [2040]|UNICARE [204000]|644.5||||644.5|22.24|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|644.5||||644.5|22.24|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WEB TPA [2115]|WEB TPA [211500]|644.5||||644.5|444.71|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|644.5||||644.5|16.18|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|644.5||||644.5|32.36|444.71|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WORKER'S COMP [2125]|TML WC [212537]|644.5||||644.5|22.24|444.71|13.59
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AARP [1000]|AARP [100000]|359.5||||359.5|6.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AETNA [1015]|AETNA [101529]|359.5||||359.5|161.78|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|359.5||||359.5|5.27|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|359.5||||359.5|179.75|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|359.5||||359.5|143.8|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|359.5||||359.5|143.8|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|359.5||||359.5|168.97|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|359.5||||359.5|147.4|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|359.5||||359.5|14.7|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|359.5||||359.5|6.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|359.5||||359.5|179.75|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|359.5||||359.5|161.78|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|359.5||||359.5|161.78|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|359.5||||359.5|0|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|Self-pay|Self-pay|359.5||||359.5|71.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|TML [1980]|TML [198000]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|359.5||||359.5|4.22|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|359.5||||359.5|6.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UNICARE [2040]|UNICARE [204000]|359.5||||359.5|6.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|359.5||||359.5|6.9|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|359.5||||359.5|248.06|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|359.5||||359.5|5.02|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|359.5||||359.5|10.04|248.06|4.22
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|359.5||||359.5|6.9|248.06|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AARP [1000]|AARP [100000]|101||||101|6.9|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA [1015]|AETNA [101529]|101||||101|45.45|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMBETTER [2930]|AMBETTER [293000]|101||||101|5.27|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101||||101|50.5|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101||||101|40.4|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101||||101|40.4|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101||||101|47.47|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|101||||101|41.41|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA [1260]|CIGNA PPO [126025]|101||||101|14.7|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101||||101|6.9|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101||||101|50.5|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101||||101|45.45|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101||||101|45.45|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101||||101|0|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|Self-pay|Self-pay|101||||101|20.2|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|TML [1980]|TML [198000]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101||||101|4.22|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101||||101|6.9|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNICARE [2040]|UNICARE [204000]|101||||101|6.9|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101||||101|6.9|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WEB TPA [2115]|WEB TPA [211500]|101||||101|69.69|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101||||101|5.02|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101||||101|10.04|69.69|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WORKER'S COMP [2125]|TML WC [212537]|101||||101|6.9|69.69|4.22
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AARP [1000]|AARP [100000]|129.5||||129.5|4.48|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA [1015]|AETNA [101529]|129.5||||129.5|58.28|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMBETTER [2930]|AMBETTER [293000]|129.5||||129.5|4.6|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|129.5||||129.5|64.75|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.5||||129.5|51.8|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.5||||129.5|51.8|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.5||||129.5|60.87|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|129.5||||129.5|53.1|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA [1260]|CIGNA PPO [126025]|129.5||||129.5|9.53|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|129.5||||129.5|4.48|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|129.5||||129.5|64.75|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.5||||129.5|58.28|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.5||||129.5|58.28|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.5||||129.5|0|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|Self-pay|Self-pay|129.5||||129.5|25.9|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|TML [1980]|TML [198000]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.5||||129.5|3.68|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.5||||129.5|4.48|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNICARE [2040]|UNICARE [204000]|129.5||||129.5|4.48|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.5||||129.5|4.48|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WEB TPA [2115]|WEB TPA [211500]|129.5||||129.5|89.36|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.5||||129.5|4.38|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.5||||129.5|8.76|89.36|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WORKER'S COMP [2125]|TML WC [212537]|129.5||||129.5|4.48|89.36|3.68
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AARP [1000]|AARP [100000]|1082.5||||1082.5|40.7|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA [1015]|AETNA [101529]|1082.5||||1082.5|487.13|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMBETTER [2930]|AMBETTER [293000]|1082.5||||1082.5|31.08|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1082.5||||1082.5|541.25|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1082.5||||1082.5|433|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1082.5||||1082.5|433|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1082.5||||1082.5|508.78|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1082.5||||1082.5|443.83|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA [1260]|CIGNA PPO [126025]|1082.5||||1082.5|86.76|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1082.5||||1082.5|40.7|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1082.5||||1082.5|541.25|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1082.5||||1082.5|487.13|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1082.5||||1082.5|487.13|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1082.5||||1082.5|0|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|Self-pay|Self-pay|1082.5||||1082.5|216.5|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|TML [1980]|TML [198000]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1082.5||||1082.5|24.86|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1082.5||||1082.5|40.7|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNICARE [2040]|UNICARE [204000]|1082.5||||1082.5|40.7|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1082.5||||1082.5|40.7|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WEB TPA [2115]|WEB TPA [211500]|1082.5||||1082.5|746.93|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1082.5||||1082.5|29.6|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1082.5||||1082.5|59.2|746.93|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WORKER'S COMP [2125]|TML WC [212537]|1082.5||||1082.5|40.7|746.93|24.86
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AARP [1000]|AARP [100000]|104||||104|7.09|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA [1015]|AETNA [101529]|104||||104|46.8|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|5.42|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|52|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|41.6|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|41.6|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|48.88|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|42.64|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|15.13|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104|7.09|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|52|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|46.8|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|46.8|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|0|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|Self-pay|Self-pay|104||||104|20.8|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|TML [1980]|TML [198000]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|4.33|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|7.09|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNICARE [2040]|UNICARE [204000]|104||||104|7.09|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|7.09|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|5.16|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|10.32|71.76|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104|7.09|71.76|4.33
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AARP [1000]|AARP [100000]|276||||276|18.79|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA [1015]|AETNA [101529]|276||||276|124.2|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMBETTER [2930]|AMBETTER [293000]|276||||276|14.36|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|276||||276|138|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|276||||276|110.4|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|276||||276|110.4|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|276||||276|129.72|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|276||||276|113.16|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA [1260]|CIGNA PPO [126025]|276||||276|40.08|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|276||||276|18.79|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|276||||276|138|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|276||||276|124.2|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|276||||276|124.2|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|276||||276|0|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|Self-pay|Self-pay|276||||276|55.2|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|TML [1980]|TML [198000]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|276||||276|11.49|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|276||||276|18.79|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNICARE [2040]|UNICARE [204000]|276||||276|18.79|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|276||||276|18.79|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WEB TPA [2115]|WEB TPA [211500]|276||||276|190.44|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|276||||276|13.68|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|276||||276|27.36|190.44|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WORKER'S COMP [2125]|TML WC [212537]|276||||276|18.79|190.44|11.49
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AARP [1000]|AARP [100000]|421||||421|26.08|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA [1015]|AETNA [101529]|421||||421|189.45|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMBETTER [2930]|AMBETTER [293000]|421||||421|19.91|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|421||||421|210.5|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|421||||421|168.4|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|421||||421|168.4|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|421||||421|197.87|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|421||||421|172.61|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA [1260]|CIGNA PPO [126025]|421||||421|55.61|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|421||||421|26.08|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|421||||421|210.5|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|421||||421|189.45|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|421||||421|189.45|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|421||||421|0|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|Self-pay|Self-pay|421||||421|84.2|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|TML [1980]|TML [198000]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|421||||421|15.93|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|421||||421|26.08|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNICARE [2040]|UNICARE [204000]|421||||421|26.08|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|421||||421|26.08|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WEB TPA [2115]|WEB TPA [211500]|421||||421|290.49|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|421||||421|18.96|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|421||||421|37.92|290.49|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WORKER'S COMP [2125]|TML WC [212537]|421||||421|26.08|290.49|15.93
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AARP [1000]|AARP [100000]|217||||217|14.76|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA [1015]|AETNA [101529]|217||||217|97.65|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMBETTER [2930]|AMBETTER [293000]|217||||217|11.28|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|217||||217|108.5|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217|86.8|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217|86.8|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217|101.99|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|217||||217|88.97|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA [1260]|CIGNA PPO [126025]|217||||217|31.48|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|217||||217|14.76|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|217||||217|108.5|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|97.65|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|97.65|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|0|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|Self-pay|Self-pay|217||||217|43.4|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|TML [1980]|TML [198000]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|9.02|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217|14.76|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNICARE [2040]|UNICARE [204000]|217||||217|14.76|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217|14.76|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WEB TPA [2115]|WEB TPA [211500]|217||||217|149.73|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217|10.74|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217|21.48|149.73|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WORKER'S COMP [2125]|TML WC [212537]|217||||217|14.76|149.73|9.02
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AARP [1000]|AARP [100000]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA [1015]|AETNA [101529]|563||||563|253.35|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|563||||563|281.5|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|563||||563|225.2|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|563||||563|225.2|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|563||||563|264.61|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|563||||563|230.83|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|563||||563|41.41|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|563||||563|281.5|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|563||||563|253.35|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|563||||563|253.35|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|563||||563|0|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|Self-pay|Self-pay|563||||563|112.6|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|TML [1980]|TML [198000]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNICARE [2040]|UNICARE [204000]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|563||||563|388.47|388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|563||||563||388.47|41.41
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|563||||563||388.47|41.41
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AARP [1000]|AARP [100000]|93||||93|6.32|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA [1015]|AETNA [101529]|93||||93|41.85|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|4.83|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|37.2|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|37.2|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|43.71|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|38.13|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|13.47|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93|6.32|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|41.85|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|41.85|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|0|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|Self-pay|Self-pay|93||||93|18.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|TML [1980]|TML [198000]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|3.86|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|6.32|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNICARE [2040]|UNICARE [204000]|93||||93|6.32|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|6.32|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|4.6|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|9.2|64.17|3.86
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93|6.32|64.17|3.86
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AARP [1000]|AARP [100000]|93||||93|6.91|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AETNA [1015]|AETNA [101529]|93||||93|41.85|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|6.04|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|37.2|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|37.2|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|43.71|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|38.13|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|14.73|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93|6.91|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|41.85|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|41.85|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|0|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|Self-pay|Self-pay|93||||93|18.6|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|TML [1980]|TML [198000]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|4.83|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|6.91|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UNICARE [2040]|UNICARE [204000]|93||||93|6.91|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|6.91|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|5.75|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|11.5|64.17|4.83
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93|6.91|64.17|4.83
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AARP [1000]|AARP [100000]|174||||174|5.98|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA [1015]|AETNA [101529]|174||||174|78.3|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|174||||174|4.57|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|174||||174|87|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174||||174|69.6|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174||||174|69.6|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174||||174|81.78|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|174||||174|71.34|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|174||||174|12.74|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|174||||174|5.98|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|174||||174|87|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174||||174|78.3|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174||||174|78.3|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174||||174|0|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|Self-pay|Self-pay|174||||174|34.8|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|TML [1980]|TML [198000]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174||||174|3.65|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174||||174|5.98|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNICARE [2040]|UNICARE [204000]|174||||174|5.98|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174||||174|5.98|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|174||||174|120.06|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174||||174|4.35|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174||||174|8.7|120.06|3.65
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|174||||174|5.98|120.06|3.65
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AARP [1000]|AARP [100000]|494.5||||494.5|17.06|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA [1015]|AETNA [101529]|494.5||||494.5|222.53|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMBETTER [2930]|AMBETTER [293000]|494.5||||494.5|13.03|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|494.5||||494.5|247.25|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|494.5||||494.5|197.8|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|494.5||||494.5|197.8|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|494.5||||494.5|232.42|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|494.5||||494.5|202.75|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA [1260]|CIGNA PPO [126025]|494.5||||494.5|36.38|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|494.5||||494.5|17.06|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|494.5||||494.5|247.25|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|494.5||||494.5|222.53|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|494.5||||494.5|222.53|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|494.5||||494.5|0|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|Self-pay|Self-pay|494.5||||494.5|98.9|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|TML [1980]|TML [198000]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|494.5||||494.5|10.42|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|494.5||||494.5|17.06|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNICARE [2040]|UNICARE [204000]|494.5||||494.5|17.06|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|494.5||||494.5|17.06|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WEB TPA [2115]|WEB TPA [211500]|494.5||||494.5|341.21|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|494.5||||494.5|12.41|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|494.5||||494.5|24.82|341.21|10.42
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WORKER'S COMP [2125]|TML WC [212537]|494.5||||494.5|17.06|341.21|10.42
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AARP [1000]|AARP [100000]|362||||362|22.41|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA [1015]|AETNA [101529]|362||||362|162.9|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|362||||362|17.12|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|362||||362|181|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|362||||362|144.8|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|362||||362|144.8|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|362||||362|170.14|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|362||||362|148.42|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|362||||362|47.8|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|362||||362|22.41|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|362||||362|181|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|362||||362|162.9|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|362||||362|162.9|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|362||||362|0|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|Self-pay|Self-pay|362||||362|72.4|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|TML [1980]|TML [198000]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|362||||362|13.69|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|362||||362|22.41|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNICARE [2040]|UNICARE [204000]|362||||362|22.41|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|362||||362|22.41|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|362||||362|249.78|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|362||||362|16.3|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|362||||362|32.6|249.78|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|362||||362|22.41|249.78|13.69
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AARP [1000]|AARP [100000]|259.75||||259.75|8.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA [1015]|AETNA [101529]|259.75||||259.75|116.89|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMBETTER [2930]|AMBETTER [293000]|259.75||||259.75|6.84|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|259.75||||259.75|129.88|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259.75||||259.75|103.9|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259.75||||259.75|103.9|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259.75||||259.75|122.08|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|259.75||||259.75|106.5|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA [1260]|CIGNA PPO [126025]|259.75||||259.75|19.1|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|259.75||||259.75|8.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|259.75||||259.75|129.88|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259.75||||259.75|116.89|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259.75||||259.75|116.89|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259.75||||259.75|0|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|Self-pay|Self-pay|259.75||||259.75|51.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|TML [1980]|TML [198000]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259.75||||259.75|5.47|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259.75||||259.75|8.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNICARE [2040]|UNICARE [204000]|259.75||||259.75|8.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259.75||||259.75|8.95|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WEB TPA [2115]|WEB TPA [211500]|259.75||||259.75|179.23|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259.75||||259.75|6.51|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259.75||||259.75|13.02|179.23|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WORKER'S COMP [2125]|TML WC [212537]|259.75||||259.75|8.95|179.23|5.47
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AARP [1000]|AARP [100000]|103||||103|7.04|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA [1015]|AETNA [101529]|103||||103|46.35|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMBETTER [2930]|AMBETTER [293000]|103||||103|5.38|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103||||103|51.5|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103||||103|41.2|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103||||103|41.2|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103||||103|48.41|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103||||103|42.23|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA [1260]|CIGNA PPO [126025]|103||||103|15.03|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103||||103|7.04|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103||||103|51.5|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103||||103|46.35|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103||||103|46.35|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103||||103|0|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|Self-pay|Self-pay|103||||103|20.6|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|TML [1980]|TML [198000]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103||||103|4.3|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103||||103|7.04|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNICARE [2040]|UNICARE [204000]|103||||103|7.04|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103||||103|7.04|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WEB TPA [2115]|WEB TPA [211500]|103||||103|71.07|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103||||103|5.12|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103||||103|10.24|71.07|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WORKER'S COMP [2125]|TML WC [212537]|103||||103|7.04|71.07|4.3
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AARP [1000]|AARP [100000]|45||||45|7.11|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|45||||45|20.25|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|45||||45|5.44|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|45||||45|22.5|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45||||45|18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45||||45|18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45||||45|21.15|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|45||||45|18.45|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|45||||45|15.16|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|45||||45|7.11|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|45||||45|22.5|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45||||45|20.25|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45||||45|20.25|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45||||45|0|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|Self-pay|Self-pay|45||||45|9|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|TML [1980]|TML [198000]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45||||45|4.35|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45||||45|7.11|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|45||||45|7.11|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45||||45|7.11|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|45||||45|31.05|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45||||45|5.18|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45||||45|10.36|31.05|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|45||||45|7.11|31.05|4.35
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AARP [1000]|AARP [100000]|190||||190|12.99|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AETNA [1015]|AETNA [101529]|190||||190|85.5|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AMBETTER [2930]|AMBETTER [293000]|190||||190|9.93|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|190||||190|95|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190||||190|76|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190||||190|76|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190||||190|89.3|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|190||||190|77.9|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA [1260]|CIGNA PPO [126025]|190||||190|27.7|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|190||||190|12.99|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|190||||190|95|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190||||190|85.5|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190||||190|85.5|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190||||190|0|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|Self-pay|Self-pay|190||||190|38|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|TML [1980]|TML [198000]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190||||190|7.95|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190||||190|12.99|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UNICARE [2040]|UNICARE [204000]|190||||190|12.99|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190||||190|12.99|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WEB TPA [2115]|WEB TPA [211500]|190||||190|131.1|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190||||190|9.46|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190||||190|18.92|131.1|7.95
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WORKER'S COMP [2125]|TML WC [212537]|190||||190|12.99|131.1|7.95
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AARP [1000]|AARP [100000]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA [1015]|AETNA [101529]|257.75||||257.75|115.99|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMBETTER [2930]|AMBETTER [293000]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|257.75||||257.75|128.88|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|257.75||||257.75|103.1|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|257.75||||257.75|103.1|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|257.75||||257.75|121.14|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|257.75||||257.75|105.68|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA [1260]|CIGNA PPO [126025]|257.75||||257.75|18.97|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|257.75||||257.75|128.88|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|257.75||||257.75|115.99|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|257.75||||257.75|115.99|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|257.75||||257.75|0|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|Self-pay|Self-pay|257.75||||257.75|51.55|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|TML [1980]|TML [198000]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNICARE [2040]|UNICARE [204000]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WEB TPA [2115]|WEB TPA [211500]|257.75||||257.75|177.85|177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|257.75||||257.75||177.85|18.97
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WORKER'S COMP [2125]|TML WC [212537]|257.75||||257.75||177.85|18.97
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AARP [1000]|AARP [100000]|600.5||||600.5|20.72|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA [1015]|AETNA [101529]|600.5||||600.5|270.23|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMBETTER [2930]|AMBETTER [293000]|600.5||||600.5|15.83|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|600.5||||600.5|300.25|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600.5||||600.5|240.2|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600.5||||600.5|240.2|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600.5||||600.5|282.24|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|600.5||||600.5|246.21|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA [1260]|CIGNA PPO [126025]|600.5||||600.5|44.19|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|600.5||||600.5|20.72|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|600.5||||600.5|300.25|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600.5||||600.5|270.23|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600.5||||600.5|270.23|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600.5||||600.5|0|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|Self-pay|Self-pay|600.5||||600.5|120.1|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|TML [1980]|TML [198000]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600.5||||600.5|12.67|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600.5||||600.5|20.72|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNICARE [2040]|UNICARE [204000]|600.5||||600.5|20.72|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600.5||||600.5|20.72|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WEB TPA [2115]|WEB TPA [211500]|600.5||||600.5|414.35|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600.5||||600.5|15.08|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600.5||||600.5|30.16|414.35|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WORKER'S COMP [2125]|TML WC [212537]|600.5||||600.5|20.72|414.35|12.67
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AARP [1000]|AARP [100000]|1381.75||||1381.75|52.92|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA [1015]|AETNA [101529]|1381.75||||1381.75|621.79|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMBETTER [2930]|AMBETTER [293000]|1381.75||||1381.75|40.43|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1381.75||||1381.75|690.88|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1381.75||||1381.75|552.7|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1381.75||||1381.75|552.7|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1381.75||||1381.75|649.42|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1381.75||||1381.75|566.52|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA [1260]|CIGNA PPO [126025]|1381.75||||1381.75|112.84|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1381.75||||1381.75|52.92|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1381.75||||1381.75|690.88|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1381.75||||1381.75|621.79|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1381.75||||1381.75|621.79|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1381.75||||1381.75|0|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|Self-pay|Self-pay|1381.75||||1381.75|276.35|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|TML [1980]|TML [198000]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1381.75||||1381.75|32.34|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1381.75||||1381.75|52.92|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNICARE [2040]|UNICARE [204000]|1381.75||||1381.75|52.92|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1381.75||||1381.75|52.92|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WEB TPA [2115]|WEB TPA [211500]|1381.75||||1381.75|953.41|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1381.75||||1381.75|38.5|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1381.75||||1381.75|77|953.41|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WORKER'S COMP [2125]|TML WC [212537]|1381.75||||1381.75|52.92|953.41|32.34
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AARP [1000]|AARP [100000]|749.25||||749.25|25.84|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA [1015]|AETNA [101529]|749.25||||749.25|337.16|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMBETTER [2930]|AMBETTER [293000]|749.25||||749.25|19.73|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|749.25||||749.25|374.63|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|749.25||||749.25|299.7|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|749.25||||749.25|299.7|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|749.25||||749.25|352.15|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|749.25||||749.25|307.19|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA [1260]|CIGNA PPO [126025]|749.25||||749.25|55.08|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|749.25||||749.25|25.84|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|749.25||||749.25|374.63|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|749.25||||749.25|337.16|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|749.25||||749.25|337.16|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|749.25||||749.25|0|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|Self-pay|Self-pay|749.25||||749.25|149.85|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|TML [1980]|TML [198000]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|749.25||||749.25|15.78|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|749.25||||749.25|25.84|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNICARE [2040]|UNICARE [204000]|749.25||||749.25|25.84|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|749.25||||749.25|25.84|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WEB TPA [2115]|WEB TPA [211500]|749.25||||749.25|516.98|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|749.25||||749.25|18.79|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|749.25||||749.25|37.58|516.98|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WORKER'S COMP [2125]|TML WC [212537]|749.25||||749.25|25.84|516.98|15.78
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AARP [1000]|AARP [100000]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AETNA [1015]|AETNA [101529]|202.75||||202.75|91.24|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AMBETTER [2930]|AMBETTER [293000]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|202.75||||202.75|101.38|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|202.75||||202.75|81.1|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|202.75||||202.75|81.1|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|202.75||||202.75|95.29|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|202.75||||202.75|83.13|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA [1260]|CIGNA PPO [126025]|202.75||||202.75|14.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|202.75||||202.75|101.38|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|202.75||||202.75|91.24|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|202.75||||202.75|91.24|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|202.75||||202.75|0|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|Self-pay|Self-pay|202.75||||202.75|40.55|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|TML [1980]|TML [198000]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UNICARE [2040]|UNICARE [204000]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WEB TPA [2115]|WEB TPA [211500]|202.75||||202.75|139.9|139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|202.75||||202.75||139.9|14.9
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WORKER'S COMP [2125]|TML WC [212537]|202.75||||202.75||139.9|14.9
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AARP [1000]|AARP [100000]|302||||302|18.73|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA [1015]|AETNA [101529]|302||||302|135.9|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMBETTER [2930]|AMBETTER [293000]|302||||302|14.31|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|302||||302|151|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|302||||302|120.8|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|302||||302|120.8|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|302||||302|141.94|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|302||||302|123.82|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA [1260]|CIGNA PPO [126025]|302||||302|39.95|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|302||||302|18.73|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|302||||302|151|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|302||||302|135.9|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|302||||302|135.9|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|302||||302|0|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|Self-pay|Self-pay|302||||302|60.4|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|TML [1980]|TML [198000]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|302||||302|11.45|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|302||||302|18.73|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNICARE [2040]|UNICARE [204000]|302||||302|18.73|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|302||||302|18.73|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WEB TPA [2115]|WEB TPA [211500]|302||||302|208.38|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|302||||302|13.63|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|302||||302|27.26|208.38|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WORKER'S COMP [2125]|TML WC [212537]|302||||302|18.73|208.38|11.45
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AARP [1000]|AARP [100000]|585.75||||585.75|20.21|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA [1015]|AETNA [101529]|585.75||||585.75|263.59|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMBETTER [2930]|AMBETTER [293000]|585.75||||585.75|15.44|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|585.75||||585.75|292.88|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|585.75||||585.75|234.3|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|585.75||||585.75|234.3|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|585.75||||585.75|275.3|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|585.75||||585.75|240.16|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|585.75||||585.75|43.1|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|585.75||||585.75|20.21|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|585.75||||585.75|292.88|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|585.75||||585.75|263.59|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|585.75||||585.75|263.59|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|585.75||||585.75|0|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|Self-pay|Self-pay|585.75||||585.75|117.15|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|TML [1980]|TML [198000]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|585.75||||585.75|12.35|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|585.75||||585.75|20.21|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNICARE [2040]|UNICARE [204000]|585.75||||585.75|20.21|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|585.75||||585.75|20.21|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WEB TPA [2115]|WEB TPA [211500]|585.75||||585.75|404.17|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|585.75||||585.75|14.7|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|585.75||||585.75|29.4|404.17|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|585.75||||585.75|20.21|404.17|12.35
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AARP [1000]|AARP [100000]|188||||188|12.78|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA [1015]|AETNA [101529]|188||||188|84.6|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMBETTER [2930]|AMBETTER [293000]|188||||188|9.77|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|188||||188|94|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|75.2|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|75.2|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|88.36|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|188||||188|77.08|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA [1260]|CIGNA PPO [126025]|188||||188|27.27|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|188||||188|12.78|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|188||||188|94|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|84.6|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|84.6|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|0|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|Self-pay|Self-pay|188||||188|37.6|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|TML [1980]|TML [198000]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|7.81|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188|12.78|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNICARE [2040]|UNICARE [204000]|188||||188|12.78|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188|12.78|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WEB TPA [2115]|WEB TPA [211500]|188||||188|129.72|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188|9.3|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188|18.6|129.72|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WORKER'S COMP [2125]|TML WC [212537]|188||||188|12.78|129.72|7.81
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AARP [1000]|AARP [100000]|365||||365|22.64|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA [1015]|AETNA [101529]|365||||365|164.25|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMBETTER [2930]|AMBETTER [293000]|365||||365|17.28|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|365||||365|182.5|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|365||||365|146|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|365||||365|146|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|365||||365|171.55|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|365||||365|149.65|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA [1260]|CIGNA PPO [126025]|365||||365|48.26|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|365||||365|22.64|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|365||||365|182.5|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|365||||365|164.25|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|365||||365|164.25|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|365||||365|0|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|Self-pay|Self-pay|365||||365|73|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|TML [1980]|TML [198000]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|365||||365|13.83|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|365||||365|22.64|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNICARE [2040]|UNICARE [204000]|365||||365|22.64|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|365||||365|22.64|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WEB TPA [2115]|WEB TPA [211500]|365||||365|251.85|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|365||||365|16.46|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|365||||365|32.92|251.85|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WORKER'S COMP [2125]|TML WC [212537]|365||||365|22.64|251.85|13.83
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AARP [1000]|AARP [100000]|933.25||||933.25|26.6|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA [1015]|AETNA [101529]|933.25||||933.25|419.96|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMBETTER [2930]|AMBETTER [293000]|933.25||||933.25|27.37|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|933.25||||933.25|466.63|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|933.25||||933.25|373.3|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|933.25||||933.25|373.3|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|933.25||||933.25|438.63|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|933.25||||933.25|382.63|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA [1260]|CIGNA PPO [126025]|933.25||||933.25|56.7|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|933.25||||933.25|26.6|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|GROUP PENSION ADMIN [1450]|GPA [145000]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|933.25||||933.25|466.63|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|933.25||||933.25|419.96|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|933.25||||933.25|419.96|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|PHCS [1780]|PHCS MULTIPLAN [178000]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|933.25||||933.25|0|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|Self-pay|Self-pay|933.25||||933.25|186.65|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|TML [1980]|TML [198000]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|933.25||||933.25|21.9|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|933.25||||933.25|26.6|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNICARE [2040]|UNICARE [204000]|933.25||||933.25|26.6|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|933.25||||933.25|26.6|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WEB TPA [2115]|WEB TPA [211500]|933.25||||933.25|643.94|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|933.25||||933.25|26.07|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|933.25||||933.25|52.14|643.94|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WORKER'S COMP [2125]|TML WC [212537]|933.25||||933.25|26.6|643.94|21.9
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AARP [1000]|AARP [100000]|244||||244|39.01|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AETNA [1015]|AETNA [101529]|244||||244|109.8|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AMBETTER [2930]|AMBETTER [293000]|244||||244|82.71|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244||||244|122|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|97.6|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|97.6|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|114.68|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244||||244|100.04|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA [1260]|CIGNA PPO [126025]|244||||244|83.15|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244||||244|39.01|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244||||244|122|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|109.8|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|109.8|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244|0|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|Self-pay|Self-pay|244||||244|48.8|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|TML [1980]|TML [198000]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244|66.17|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244|39.01|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UNICARE [2040]|UNICARE [204000]|244||||244|39.01|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244|39.01|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WEB TPA [2115]|WEB TPA [211500]|244||||244|168.36|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244|78.77|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244|157.54|168.36|39.01
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WORKER'S COMP [2125]|TML WC [212537]|244||||244|39.01|168.36|39.01
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AARP [1000]|AARP [100000]|79||||79|5.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA [1015]|AETNA [101529]|79||||79|35.55|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMBETTER [2930]|AMBETTER [293000]|79||||79|4.13|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79||||79|39.5|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79||||79|31.6|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79||||79|31.6|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79||||79|37.13|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79||||79|32.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA [1260]|CIGNA PPO [126025]|79||||79|11.52|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79||||79|5.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79||||79|39.5|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79||||79|35.55|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79||||79|35.55|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79||||79|0|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|Self-pay|Self-pay|79||||79|15.8|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|TML [1980]|TML [198000]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79||||79|3.3|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79||||79|5.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNICARE [2040]|UNICARE [204000]|79||||79|5.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79||||79|5.39|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WEB TPA [2115]|WEB TPA [211500]|79||||79|54.51|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79||||79|3.93|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79||||79|7.86|54.51|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WORKER'S COMP [2125]|TML WC [212537]|79||||79|5.39|54.51|3.3
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AARP [1000]|AARP [100000]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AETNA [1015]|AETNA [101529]|177||||177|79.65|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|177||||177|88.5|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|177||||177|70.8|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|177||||177|70.8|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|177||||177|83.19|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|177||||177|72.57|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|177||||177|17.74|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|177||||177|88.5|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|177||||177|79.65|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|177||||177|79.65|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|177||||177|0|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|Self-pay|Self-pay|177||||177|35.4|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|TML [1980]|TML [198000]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|UNICARE [2040]|UNICARE [204000]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|177||||177|122.13|122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|177||||177||122.13|17.74
30182960|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|177||||177||122.13|17.74
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AARP [1000]|AARP [100000]|10||||10|3.22|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA [1015]|AETNA [101529]|10||||10|4.5|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|10||||10|3.44|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10||||10|5|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10||||10|4|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10||||10|4|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10||||10|4.7|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10||||10|4.1|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|10||||10|6.85|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10||||10|3.22|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10||||10|5|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10||||10|4.5|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10||||10|4.5|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10||||10|0|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|Self-pay|Self-pay|10||||10|2|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|TML [1980]|TML [198000]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10||||10|1.4|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10||||10|3.22|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNICARE [2040]|UNICARE [204000]|10||||10|3.22|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10||||10|3.22|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|10||||10|6.9|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10||||10|3.28|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10||||10|6.56|6.9|1.4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|10||||10|3.22|6.9|1.4
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AARP [1000]|AARP [100000]|109||||109|9.9|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA [1015]|AETNA [101529]|109||||109|49.05|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMBETTER [2930]|AMBETTER [293000]|109||||109|7.56|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109||||109|54.5|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109||||109|43.6|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109||||109|43.6|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109||||109|51.23|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109||||109|44.69|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA [1260]|CIGNA PPO [126025]|109||||109|21.12|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109||||109|9.9|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109||||109|54.5|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109||||109|49.05|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109||||109|49.05|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109||||109|0|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|Self-pay|Self-pay|109||||109|21.8|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|TML [1980]|TML [198000]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109||||109|6.05|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109||||109|9.9|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNICARE [2040]|UNICARE [204000]|109||||109|9.9|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109||||109|9.9|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WEB TPA [2115]|WEB TPA [211500]|109||||109|75.21|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109||||109|7.2|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109||||109|14.4|75.21|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WORKER'S COMP [2125]|TML WC [212537]|109||||109|9.9|75.21|6.05
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AARP [1000]|AARP [100000]|254||||254|17.29|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA [1015]|AETNA [101529]|254||||254|114.3|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMBETTER [2930]|AMBETTER [293000]|254||||254|13.21|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|254||||254|127|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|254||||254|101.6|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|254||||254|101.6|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|254||||254|119.38|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|254||||254|104.14|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA [1260]|CIGNA PPO [126025]|254||||254|36.84|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|254||||254|17.29|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|254||||254|127|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|254||||254|114.3|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|254||||254|114.3|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|254||||254|0|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|Self-pay|Self-pay|254||||254|50.8|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|TML [1980]|TML [198000]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|254||||254|10.57|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|254||||254|17.29|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNICARE [2040]|UNICARE [204000]|254||||254|17.29|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|254||||254|17.29|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WEB TPA [2115]|WEB TPA [211500]|254||||254|175.26|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|254||||254|12.58|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|254||||254|25.16|175.26|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WORKER'S COMP [2125]|TML WC [212537]|254||||254|17.29|175.26|10.57
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AARP [1000]|AARP [100000]|513||||513|17.69|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA [1015]|AETNA [101529]|513||||513|230.85|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMBETTER [2930]|AMBETTER [293000]|513||||513|13.51|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|513||||513|256.5|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|513||||513|205.2|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|513||||513|205.2|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|513||||513|241.11|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|513||||513|210.33|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA [1260]|CIGNA PPO [126025]|513||||513|37.7|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|513||||513|17.69|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|513||||513|256.5|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|513||||513|230.85|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|513||||513|230.85|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|513||||513|0|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|Self-pay|Self-pay|513||||513|102.6|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|TML [1980]|TML [198000]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|513||||513|10.81|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|513||||513|17.69|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNICARE [2040]|UNICARE [204000]|513||||513|17.69|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|513||||513|17.69|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WEB TPA [2115]|WEB TPA [211500]|513||||513|353.97|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|513||||513|12.87|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|513||||513|25.74|353.97|10.81
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WORKER'S COMP [2125]|TML WC [212537]|513||||513|17.69|353.97|10.81
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AARP [1000]|AARP [100000]|138.12||||138.12|13.34|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA [1015]|AETNA [101529]|138.12||||138.12|62.15|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMBETTER [2930]|AMBETTER [293000]|138.12||||138.12|10.2|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|138.12||||138.12|69.06|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.12||||138.12|55.25|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.12||||138.12|55.25|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.12||||138.12|64.92|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|138.12||||138.12|56.63|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA [1260]|CIGNA PPO [126025]|138.12||||138.12|28.43|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|138.12||||138.12|13.34|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|138.12||||138.12|69.06|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.12||||138.12|62.15|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.12||||138.12|62.15|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.12||||138.12|0|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|Self-pay|Self-pay|138.12||||138.12|27.62|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|TML [1980]|TML [198000]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.12||||138.12|8.16|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.12||||138.12|13.34|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNICARE [2040]|UNICARE [204000]|138.12||||138.12|13.34|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.12||||138.12|13.34|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WEB TPA [2115]|WEB TPA [211500]|138.12||||138.12|95.3|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.12||||138.12|9.71|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.12||||138.12|19.42|95.3|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WORKER'S COMP [2125]|TML WC [212537]|138.12||||138.12|13.34|95.3|8.16
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AARP [1000]|AARP [100000]|672||||672|23.19|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AETNA [1015]|AETNA [101529]|672||||672|302.4|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AMBETTER [2930]|AMBETTER [293000]|672||||672|18.82|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|672||||672|336|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|672||||672|268.8|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|672||||672|268.8|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|672||||672|315.84|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|672||||672|275.52|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA [1260]|CIGNA PPO [126025]|672||||672|49.45|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|672||||672|23.19|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|672||||672|336|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|672||||672|302.4|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|672||||672|302.4|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|672||||672|0|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|Self-pay|Self-pay|672||||672|134.4|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|TML [1980]|TML [198000]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|672||||672|15.05|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|672||||672|23.19|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UNICARE [2040]|UNICARE [204000]|672||||672|23.19|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|672||||672|23.19|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WEB TPA [2115]|WEB TPA [211500]|672||||672|463.68|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|672||||672|17.92|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|672||||672|35.84|463.68|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WORKER'S COMP [2125]|TML WC [212537]|672||||672|23.19|463.68|15.05
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AARP [1000]|AARP [100000]|443.25||||443.25|15.86|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA [1015]|AETNA [101529]|443.25||||443.25|199.46|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMBETTER [2930]|AMBETTER [293000]|443.25||||443.25|12.11|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|443.25||||443.25|221.63|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|443.25||||443.25|177.3|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|443.25||||443.25|177.3|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|443.25||||443.25|208.33|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|443.25||||443.25|181.73|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA PPO [126025]|443.25||||443.25|33.8|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|443.25||||443.25|15.86|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|443.25||||443.25|221.63|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|443.25||||443.25|199.46|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|443.25||||443.25|199.46|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|443.25||||443.25|0|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|Self-pay|Self-pay|443.25||||443.25|88.65|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|TML [1980]|TML [198000]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|443.25||||443.25|9.69|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|443.25||||443.25|15.86|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNICARE [2040]|UNICARE [204000]|443.25||||443.25|15.86|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|443.25||||443.25|15.86|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WEB TPA [2115]|WEB TPA [211500]|443.25||||443.25|305.84|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|443.25||||443.25|11.53|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|443.25||||443.25|23.06|305.84|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TML WC [212537]|443.25||||443.25|15.86|305.84|9.69
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AARP [1000]|AARP [100000]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA [1015]|AETNA [101529]|1457||||1457|655.65|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMBETTER [2930]|AMBETTER [293000]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1457||||1457|728.5|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1457||||1457|582.8|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1457||||1457|582.8|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1457||||1457|684.79|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1457||||1457|597.37|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA [1260]|CIGNA PPO [126025]|1457||||1457|39.59|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1457||||1457|728.5|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1457||||1457|655.65|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1457||||1457|655.65|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1457||||1457|0|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|Self-pay|Self-pay|1457||||1457|291.4|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|TML [1980]|TML [198000]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNICARE [2040]|UNICARE [204000]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WEB TPA [2115]|WEB TPA [211500]|1457||||1457|1005.33|1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1457||||1457||1005.33|39.59
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WORKER'S COMP [2125]|TML WC [212537]|1457||||1457||1005.33|39.59
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AARP [1000]|AARP [100000]|563||||563|17.8|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA [1015]|AETNA [101529]|563||||563|253.35|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMBETTER [2930]|AMBETTER [293000]|563||||563|18.13|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|563||||563|281.5|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|563||||563|225.2|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|563||||563|225.2|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|563||||563|264.61|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|563||||563|230.83|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA [1260]|CIGNA PPO [126025]|563||||563|37.93|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|563||||563|17.8|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|563||||563|281.5|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|563||||563|253.35|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|563||||563|253.35|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|563||||563|0|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|Self-pay|Self-pay|563||||563|112.6|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|TML [1980]|TML [198000]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|563||||563|14.51|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|563||||563|17.8|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNICARE [2040]|UNICARE [204000]|563||||563|17.8|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|563||||563|17.8|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WEB TPA [2115]|WEB TPA [211500]|563||||563|388.47|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|563||||563|17.27|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|563||||563|34.54|388.47|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WORKER'S COMP [2125]|TML WC [212537]|563||||563|17.8|388.47|14.51
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AARP [1000]|AARP [100000]|455.25||||455.25|15.71|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA [1015]|AETNA [101529]|455.25||||455.25|204.86|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|455.25||||455.25|12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|455.25||||455.25|227.63|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|455.25||||455.25|182.1|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|455.25||||455.25|182.1|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|455.25||||455.25|213.97|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|455.25||||455.25|186.65|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|455.25||||455.25|33.5|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|455.25||||455.25|15.71|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|455.25||||455.25|227.63|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|455.25||||455.25|204.86|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|455.25||||455.25|204.86|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|455.25||||455.25|0|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|Self-pay|Self-pay|455.25||||455.25|91.05|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|TML [1980]|TML [198000]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|455.25||||455.25|9.6|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|455.25||||455.25|15.71|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNICARE [2040]|UNICARE [204000]|455.25||||455.25|15.71|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|455.25||||455.25|15.71|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|455.25||||455.25|314.12|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|455.25||||455.25|11.43|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|455.25||||455.25|22.86|314.12|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|455.25||||455.25|15.71|314.12|9.6
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AARP [1000]|AARP [100000]|131||||131|8.9|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA [1015]|AETNA [101529]|131||||131|58.95|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMBETTER [2930]|AMBETTER [293000]|131||||131|6.79|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131||||131|65.5|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131||||131|52.4|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131||||131|52.4|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131||||131|61.57|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131||||131|53.71|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA [1260]|CIGNA PPO [126025]|131||||131|18.97|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131||||131|8.9|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131||||131|65.5|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131||||131|58.95|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131||||131|58.95|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131||||131|0|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|Self-pay|Self-pay|131||||131|26.2|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|TML [1980]|TML [198000]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131||||131|5.43|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131||||131|8.9|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNICARE [2040]|UNICARE [204000]|131||||131|8.9|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131||||131|8.9|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WEB TPA [2115]|WEB TPA [211500]|131||||131|90.39|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131||||131|6.47|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131||||131|12.94|90.39|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WORKER'S COMP [2125]|TML WC [212537]|131||||131|8.9|90.39|5.43
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AARP [1000]|AARP [100000]|177||||177|12.02|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA [1015]|AETNA [101529]|177||||177|79.65|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMBETTER [2930]|AMBETTER [293000]|177||||177|9.18|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|177||||177|88.5|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|177||||177|70.8|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|177||||177|70.8|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|177||||177|83.19|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|177||||177|72.57|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA [1260]|CIGNA PPO [126025]|177||||177|25.62|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|177||||177|12.02|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|177||||177|88.5|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|177||||177|79.65|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|177||||177|79.65|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|177||||177|0|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|Self-pay|Self-pay|177||||177|35.4|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|TML [1980]|TML [198000]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|177||||177|7.34|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|177||||177|12.02|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNICARE [2040]|UNICARE [204000]|177||||177|12.02|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|177||||177|12.02|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WEB TPA [2115]|WEB TPA [211500]|177||||177|122.13|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|177||||177|8.74|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|177||||177|17.48|122.13|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WORKER'S COMP [2125]|TML WC [212537]|177||||177|12.02|122.13|7.34
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AARP [1000]|AARP [100000]|215||||215|14.68|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA [1015]|AETNA [101529]|215||||215|96.75|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMBETTER [2930]|AMBETTER [293000]|215||||215|12.15|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|215||||215|107.5|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215||||215|86|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215||||215|86|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215||||215|101.05|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|215||||215|88.15|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA [1260]|CIGNA PPO [126025]|215||||215|31.31|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|215||||215|14.68|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|215||||215|107.5|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215||||215|96.75|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215||||215|96.75|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215||||215|0|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|Self-pay|Self-pay|215||||215|43|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|TML [1980]|TML [198000]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215||||215|9.72|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215||||215|14.68|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNICARE [2040]|UNICARE [204000]|215||||215|14.68|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215||||215|14.68|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WEB TPA [2115]|WEB TPA [211500]|215||||215|148.35|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215||||215|11.57|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215||||215|23.14|148.35|9.72
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WORKER'S COMP [2125]|TML WC [212537]|215||||215|14.68|148.35|9.72
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AARP [1000]|AARP [100000]|122||||122|8.3|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA [1015]|AETNA [101529]|122||||122|54.9|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMBETTER [2930]|AMBETTER [293000]|122||||122|6.34|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122||||122|61|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|48.8|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|48.8|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|57.34|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122||||122|50.02|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA [1260]|CIGNA PPO [126025]|122||||122|17.68|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122||||122|8.3|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122||||122|61|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|54.9|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|54.9|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122|0|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|Self-pay|Self-pay|122||||122|24.4|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|TML [1980]|TML [198000]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122|5.07|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122|8.3|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNICARE [2040]|UNICARE [204000]|122||||122|8.3|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122|8.3|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WEB TPA [2115]|WEB TPA [211500]|122||||122|84.18|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122|6.04|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122|12.08|84.18|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WORKER'S COMP [2125]|TML WC [212537]|122||||122|8.3|84.18|5.07
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AARP [1000]|AARP [100000]|139||||139|9.47|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA [1015]|AETNA [101529]|139||||139|62.55|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMBETTER [2930]|AMBETTER [293000]|139||||139|7.23|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139||||139|69.5|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139||||139|55.6|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139||||139|55.6|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139||||139|65.33|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139||||139|56.99|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA [1260]|CIGNA PPO [126025]|139||||139|20.19|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139||||139|9.47|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139||||139|69.5|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139||||139|62.55|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139||||139|62.55|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139||||139|0|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|Self-pay|Self-pay|139||||139|27.8|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|TML [1980]|TML [198000]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139||||139|5.79|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139||||139|9.47|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNICARE [2040]|UNICARE [204000]|139||||139|9.47|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139||||139|9.47|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WEB TPA [2115]|WEB TPA [211500]|139||||139|95.91|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139||||139|6.89|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139||||139|13.78|95.91|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WORKER'S COMP [2125]|TML WC [212537]|139||||139|9.47|95.91|5.79
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AARP [1000]|AARP [100000]|135||||135|9.21|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA [1015]|AETNA [101529]|135||||135|60.75|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMBETTER [2930]|AMBETTER [293000]|135||||135|7.04|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|135||||135|67.5|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|54|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135|54|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135|63.45|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|135||||135|55.35|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA [1260]|CIGNA PPO [126025]|135||||135|19.63|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|135||||135|9.21|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|135||||135|67.5|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135|60.75|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135|60.75|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|0|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|Self-pay|Self-pay|135||||135|27|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|TML [1980]|TML [198000]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|5.63|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135|9.21|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNICARE [2040]|UNICARE [204000]|135||||135|9.21|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135|9.21|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WEB TPA [2115]|WEB TPA [211500]|135||||135|93.15|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135|6.7|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135|13.4|93.15|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WORKER'S COMP [2125]|TML WC [212537]|135||||135|9.21|93.15|5.63
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AARP [1000]|AARP [100000]|675.25||||675.25|23.29|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AETNA [1015]|AETNA [101529]|675.25||||675.25|303.86|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AMBETTER [2930]|AMBETTER [293000]|675.25||||675.25|17.79|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|675.25||||675.25|337.63|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|675.25||||675.25|270.1|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|675.25||||675.25|270.1|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|675.25||||675.25|317.37|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|675.25||||675.25|276.85|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA [1260]|CIGNA PPO [126025]|675.25||||675.25|49.65|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|675.25||||675.25|23.29|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|675.25||||675.25|337.63|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|675.25||||675.25|303.86|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|675.25||||675.25|303.86|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|675.25||||675.25|0|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|Self-pay|Self-pay|675.25||||675.25|135.05|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|TML [1980]|TML [198000]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|675.25||||675.25|14.23|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|675.25||||675.25|23.29|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UNICARE [2040]|UNICARE [204000]|675.25||||675.25|23.29|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|675.25||||675.25|23.29|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WEB TPA [2115]|WEB TPA [211500]|675.25||||675.25|465.92|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|675.25||||675.25|16.94|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|675.25||||675.25|33.88|465.92|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WORKER'S COMP [2125]|TML WC [212537]|675.25||||675.25|23.29|465.92|14.23
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AARP [1000]|AARP [100000]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA [1015]|AETNA [101529]|514.5||||514.5|231.53|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMBETTER [2930]|AMBETTER [293000]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|514.5||||514.5|257.25|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|514.5||||514.5|205.8|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|514.5||||514.5|205.8|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|514.5||||514.5|241.82|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|514.5||||514.5|210.95|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA [1260]|CIGNA PPO [126025]|514.5||||514.5|37.83|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|514.5||||514.5|257.25|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|514.5||||514.5|231.53|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|514.5||||514.5|231.53|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|514.5||||514.5|0|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|Self-pay|Self-pay|514.5||||514.5|102.9|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|TML [1980]|TML [198000]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNICARE [2040]|UNICARE [204000]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WEB TPA [2115]|WEB TPA [211500]|514.5||||514.5|355.01|355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|514.5||||514.5||355.01|37.83
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WORKER'S COMP [2125]|TML WC [212537]|514.5||||514.5||355.01|37.83
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AARP [1000]|AARP [100000]|516||||516|46.66|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA [1015]|AETNA [101529]|516||||516|232.2|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMBETTER [2930]|AMBETTER [293000]|516||||516|41.22|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|516||||516|258|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|516||||516|206.4|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|516||||516|206.4|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|516||||516|242.52|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|516||||516|211.56|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA [1260]|CIGNA PPO [126025]|516||||516|99.5|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|516||||516|46.66|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|516||||516|258|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|516||||516|232.2|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|516||||516|232.2|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|516||||516|0|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|Self-pay|Self-pay|516||||516|103.2|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|TML [1980]|TML [198000]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|516||||516|32.98|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|516||||516|46.66|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNICARE [2040]|UNICARE [204000]|516||||516|46.66|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|516||||516|46.66|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WEB TPA [2115]|WEB TPA [211500]|516||||516|356.04|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|516||||516|39.26|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|516||||516|78.52|356.04|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WORKER'S COMP [2125]|TML WC [212537]|516||||516|46.66|356.04|32.98
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AARP [1000]|AARP [100000]|541.5||||541.5|18.69|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA [1015]|AETNA [101529]|541.5||||541.5|243.68|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMBETTER [2930]|AMBETTER [293000]|541.5||||541.5|14.28|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|541.5||||541.5|270.75|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|541.5||||541.5|216.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|541.5||||541.5|216.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|541.5||||541.5|254.51|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|541.5||||541.5|222.02|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA [1260]|CIGNA PPO [126025]|541.5||||541.5|39.85|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|541.5||||541.5|18.69|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|541.5||||541.5|270.75|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|541.5||||541.5|243.68|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|541.5||||541.5|243.68|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|541.5||||541.5|0|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|Self-pay|Self-pay|541.5||||541.5|108.3|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|TML [1980]|TML [198000]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|541.5||||541.5|11.42|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|541.5||||541.5|18.69|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNICARE [2040]|UNICARE [204000]|541.5||||541.5|18.69|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|541.5||||541.5|18.69|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WEB TPA [2115]|WEB TPA [211500]|541.5||||541.5|373.64|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|541.5||||541.5|13.6|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|541.5||||541.5|27.2|373.64|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WORKER'S COMP [2125]|TML WC [212537]|541.5||||541.5|18.69|373.64|11.42
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AARP [1000]|AARP [100000]|656||||656|22.62|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA [1015]|AETNA [101529]|656||||656|295.2|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMBETTER [2930]|AMBETTER [293000]|656||||656|22.27|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|656||||656|328|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|656||||656|262.4|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|656||||656|262.4|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|656||||656|308.32|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|656||||656|268.96|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA [1260]|CIGNA PPO [126025]|656||||656|48.23|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|656||||656|22.62|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|656||||656|328|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|656||||656|295.2|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|656||||656|295.2|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|656||||656|0|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|Self-pay|Self-pay|656||||656|131.2|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|TML [1980]|TML [198000]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|656||||656|17.82|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|656||||656|22.62|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNICARE [2040]|UNICARE [204000]|656||||656|22.62|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|656||||656|22.62|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WEB TPA [2115]|WEB TPA [211500]|656||||656|452.64|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|656||||656|21.21|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|656||||656|42.42|452.64|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WORKER'S COMP [2125]|TML WC [212537]|656||||656|22.62|452.64|17.82
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AARP [1000]|AARP [100000]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA [1015]|AETNA [101529]|109||||109|49.05|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMBETTER [2930]|AMBETTER [293000]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109||||109|54.5|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109||||109|43.6|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109||||109|43.6|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109||||109|51.23|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109||||109|44.69|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA [1260]|CIGNA PPO [126025]|109||||109|19.4|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109||||109|54.5|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109||||109|49.05|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109||||109|49.05|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109||||109|0|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|Self-pay|Self-pay|109||||109|21.8|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|TML [1980]|TML [198000]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNICARE [2040]|UNICARE [204000]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WEB TPA [2115]|WEB TPA [211500]|109||||109|75.21|75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109||||109||75.21|19.4
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WORKER'S COMP [2125]|TML WC [212537]|109||||109||75.21|19.4
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AARP [1000]|AARP [100000]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA [1015]|AETNA [101529]|99||||99|44.55|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMBETTER [2930]|AMBETTER [293000]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99||||99|49.5|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|39.6|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|39.6|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|46.53|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99||||99|40.59|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA [1260]|CIGNA PPO [126025]|99||||99|19.99|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99||||99|49.5|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|44.55|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|44.55|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99|0|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|Self-pay|Self-pay|99||||99|19.8|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|TML [1980]|TML [198000]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNICARE [2040]|UNICARE [204000]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WEB TPA [2115]|WEB TPA [211500]|99||||99|68.31|68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99||68.31|19.8
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WORKER'S COMP [2125]|TML WC [212537]|99||||99||68.31|19.8
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AARP [1000]|AARP [100000]|1392.5||||1392.5|56.74|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA [1015]|AETNA [101529]|1392.5||||1392.5|626.63|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMBETTER [2930]|AMBETTER [293000]|1392.5||||1392.5|43.34|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1392.5||||1392.5|696.25|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1392.5||||1392.5|557|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1392.5||||1392.5|557|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1392.5||||1392.5|654.48|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1392.5||||1392.5|570.93|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA [1260]|CIGNA PPO [126025]|1392.5||||1392.5|120.98|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1392.5||||1392.5|56.74|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1392.5||||1392.5|696.25|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1392.5||||1392.5|626.63|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1392.5||||1392.5|626.63|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1392.5||||1392.5|0|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|Self-pay|Self-pay|1392.5||||1392.5|278.5|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|TML [1980]|TML [198000]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1392.5||||1392.5|34.68|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1392.5||||1392.5|56.74|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNICARE [2040]|UNICARE [204000]|1392.5||||1392.5|56.74|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1392.5||||1392.5|56.74|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WEB TPA [2115]|WEB TPA [211500]|1392.5||||1392.5|960.83|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1392.5||||1392.5|41.28|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1392.5||||1392.5|82.56|960.83|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WORKER'S COMP [2125]|TML WC [212537]|1392.5||||1392.5|56.74|960.83|34.68
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AARP [1000]|AARP [100000]|96||||96|6.52|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA [1015]|AETNA [101529]|96||||96|43.2|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMBETTER [2930]|AMBETTER [293000]|96||||96|4.98|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|96||||96|48|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|38.4|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|38.4|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|45.12|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|96||||96|39.36|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA [1260]|CIGNA PPO [126025]|96||||96|13.9|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|96||||96|6.52|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|96||||96|48|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|43.2|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|43.2|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96|0|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|Self-pay|Self-pay|96||||96|19.2|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|TML [1980]|TML [198000]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96|3.98|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96|6.52|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNICARE [2040]|UNICARE [204000]|96||||96|6.52|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96|6.52|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WEB TPA [2115]|WEB TPA [211500]|96||||96|66.24|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96|4.74|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96|9.48|66.24|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WORKER'S COMP [2125]|TML WC [212537]|96||||96|6.52|66.24|3.98
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AARP [1000]|AARP [100000]|93||||93|6.32|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA [1015]|AETNA [101529]|93||||93|41.85|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|5|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|37.2|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|37.2|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|43.71|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|38.13|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|13.47|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93|6.32|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|41.85|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|41.85|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|0|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|Self-pay|Self-pay|93||||93|18.6|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|TML [1980]|TML [198000]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|4|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|6.32|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNICARE [2040]|UNICARE [204000]|93||||93|6.32|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|6.32|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|4.76|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|9.52|64.17|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93|6.32|64.17|4
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AARP [1000]|AARP [100000]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AETNA [1015]|AETNA [101529]|93||||93|41.85|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AMBETTER [2930]|AMBETTER [293000]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|37.2|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|37.2|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|43.71|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|38.13|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|12.61|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|41.85|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|41.85|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|0|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|Self-pay|Self-pay|93||||93|18.6|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|TML [1980]|TML [198000]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UNICARE [2040]|UNICARE [204000]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93||64.17|12.61
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93||64.17|12.61
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AARP [1000]|AARP [100000]|170||||170|20.05|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA [1015]|AETNA [101529]|170||||170|76.5|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMBETTER [2930]|AMBETTER [293000]|170||||170|15.32|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|170||||170|85|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170||||170|68|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170||||170|68|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170||||170|79.9|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|170||||170|69.7|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA [1260]|CIGNA PPO [126025]|170||||170|42.77|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|170||||170|20.05|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|170||||170|85|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170||||170|76.5|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170||||170|76.5|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170||||170|0|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|Self-pay|Self-pay|170||||170|34|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|TML [1980]|TML [198000]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170||||170|12.26|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170||||170|20.05|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNICARE [2040]|UNICARE [204000]|170||||170|20.05|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170||||170|20.05|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WEB TPA [2115]|WEB TPA [211500]|170||||170|117.3|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170||||170|14.59|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170||||170|29.18|117.3|12.26
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WORKER'S COMP [2125]|TML WC [212537]|170||||170|20.05|117.3|12.26
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AARP [1000]|AARP [100000]|958.25||||958.25|36.82|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA [1015]|AETNA [101529]|958.25||||958.25|431.21|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMBETTER [2930]|AMBETTER [293000]|958.25||||958.25|28.58|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|958.25||||958.25|479.13|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|958.25||||958.25|383.3|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|958.25||||958.25|383.3|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|958.25||||958.25|450.38|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|958.25||||958.25|392.88|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA [1260]|CIGNA PPO [126025]|958.25||||958.25|78.51|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|958.25||||958.25|36.82|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|958.25||||958.25|479.13|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|958.25||||958.25|431.21|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|958.25||||958.25|431.21|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|958.25||||958.25|0|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|Self-pay|Self-pay|958.25||||958.25|191.65|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|TML [1980]|TML [198000]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|958.25||||958.25|22.86|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|958.25||||958.25|36.82|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNICARE [2040]|UNICARE [204000]|958.25||||958.25|36.82|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|958.25||||958.25|36.82|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WEB TPA [2115]|WEB TPA [211500]|958.25||||958.25|661.19|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|958.25||||958.25|27.22|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|958.25||||958.25|54.44|661.19|22.86
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WORKER'S COMP [2125]|TML WC [212537]|958.25||||958.25|36.82|661.19|22.86
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AARP [1000]|AARP [100000]|430||||430|26.64|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AETNA [1015]|AETNA [101529]|430||||430|193.5|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AMBETTER [2930]|AMBETTER [293000]|430||||430|20.35|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|430||||430|215|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|172|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|172|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|202.1|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|430||||430|176.3|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA [1260]|CIGNA PPO [126025]|430||||430|56.8|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|430||||430|26.64|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|430||||430|215|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|193.5|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|193.5|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|0|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|Self-pay|Self-pay|430||||430|86|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|TML [1980]|TML [198000]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|16.28|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430|26.64|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UNICARE [2040]|UNICARE [204000]|430||||430|26.64|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430|26.64|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WEB TPA [2115]|WEB TPA [211500]|430||||430|296.7|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430|19.38|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430|38.76|296.7|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WORKER'S COMP [2125]|TML WC [212537]|430||||430|26.64|296.7|16.28
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AARP [1000]|AARP [100000]|408||||408|25.29|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA [1015]|AETNA [101529]|408||||408|183.6|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|408||||408|19.31|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408||||408|204|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408||||408|163.2|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408||||408|163.2|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408||||408|191.76|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408||||408|167.28|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|408||||408|53.92|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408||||408|25.29|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408||||408|204|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408||||408|183.6|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408||||408|183.6|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408||||408|0|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|Self-pay|Self-pay|408||||408|81.6|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|TML [1980]|TML [198000]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408||||408|15.45|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408||||408|25.29|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNICARE [2040]|UNICARE [204000]|408||||408|25.29|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408||||408|25.29|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|408||||408|281.52|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408||||408|18.39|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408||||408|36.78|281.52|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|408||||408|25.29|281.52|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AARP [1000]|AARP [100000]|732.75||||732.75|25.29|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AETNA [1015]|AETNA [101529]|732.75||||732.75|329.74|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AMBETTER [2930]|AMBETTER [293000]|732.75||||732.75|19.31|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|732.75||||732.75|366.38|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|732.75||||732.75|293.1|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|732.75||||732.75|293.1|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|732.75||||732.75|344.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|732.75||||732.75|300.43|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA [1260]|CIGNA PPO [126025]|732.75||||732.75|53.92|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|732.75||||732.75|25.29|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|732.75||||732.75|366.38|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|732.75||||732.75|329.74|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|732.75||||732.75|329.74|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|732.75||||732.75|0|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|Self-pay|Self-pay|732.75||||732.75|146.55|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|TML [1980]|TML [198000]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|732.75||||732.75|15.45|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|732.75||||732.75|25.29|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UNICARE [2040]|UNICARE [204000]|732.75||||732.75|25.29|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|732.75||||732.75|25.29|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WEB TPA [2115]|WEB TPA [211500]|732.75||||732.75|505.6|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|732.75||||732.75|18.39|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|732.75||||732.75|36.78|505.6|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WORKER'S COMP [2125]|TML WC [212537]|732.75||||732.75|25.29|505.6|15.45
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AARP [1000]|AARP [100000]|74||||74|5.04|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|74||||74|33.3|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMBETTER [2930]|AMBETTER [293000]|74||||74|3.85|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|74||||74|37|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74||||74|29.6|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74||||74|29.6|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74||||74|34.78|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|74||||74|30.34|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|74||||74|10.76|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|74||||74|5.04|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|74||||74|37|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74||||74|33.3|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74||||74|33.3|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74||||74|0|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|Self-pay|Self-pay|74||||74|14.8|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|TML [1980]|TML [198000]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74||||74|3.08|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74||||74|5.04|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNICARE [2040]|UNICARE [204000]|74||||74|5.04|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74||||74|5.04|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WEB TPA [2115]|WEB TPA [211500]|74||||74|51.06|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74||||74|3.67|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74||||74|7.34|51.06|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|74||||74|5.04|51.06|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AARP [1000]|AARP [100000]|48||||48|5.04|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA [1015]|AETNA [101529]|48||||48|21.6|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMBETTER [2930]|AMBETTER [293000]|48||||48|3.85|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48||||48|24|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48||||48|19.2|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48||||48|19.2|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48||||48|22.56|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48||||48|19.68|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA [1260]|CIGNA PPO [126025]|48||||48|10.76|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48||||48|5.04|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48||||48|24|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48||||48|21.6|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48||||48|21.6|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48||||48|0|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|Self-pay|Self-pay|48||||48|9.6|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|TML [1980]|TML [198000]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48||||48|3.08|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48||||48|5.04|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNICARE [2040]|UNICARE [204000]|48||||48|5.04|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48||||48|5.04|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WEB TPA [2115]|WEB TPA [211500]|48||||48|33.12|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48||||48|3.67|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48||||48|7.34|33.12|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WORKER'S COMP [2125]|TML WC [212537]|48||||48|5.04|33.12|3.08
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AARP [1000]|AARP [100000]|74||||74|5.04|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA [1015]|AETNA [101529]|74||||74|33.3|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMBETTER [2930]|AMBETTER [293000]|74||||74|4.2|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|74||||74|37|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74||||74|29.6|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74||||74|29.6|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74||||74|34.78|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|74||||74|30.34|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA [1260]|CIGNA PPO [126025]|74||||74|10.76|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|74||||74|5.04|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|74||||74|37|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74||||74|33.3|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74||||74|33.3|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74||||74|0|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|Self-pay|Self-pay|74||||74|14.8|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|TML [1980]|TML [198000]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74||||74|3.36|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74||||74|5.04|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNICARE [2040]|UNICARE [204000]|74||||74|5.04|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74||||74|5.04|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WEB TPA [2115]|WEB TPA [211500]|74||||74|51.06|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74||||74|4|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74||||74|8|51.06|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WORKER'S COMP [2125]|TML WC [212537]|74||||74|5.04|51.06|3.36
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AARP [1000]|AARP [100000]|428||||428|14.76|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AETNA [1015]|AETNA [101529]|428||||428|192.6|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AMBETTER [2930]|AMBETTER [293000]|428||||428|11.28|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|428||||428|214|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|428||||428|171.2|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|428||||428|171.2|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|428||||428|201.16|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|428||||428|175.48|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|428||||428|31.48|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|428||||428|14.76|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|428||||428|214|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|428||||428|192.6|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|428||||428|192.6|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|428||||428|0|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|Self-pay|Self-pay|428||||428|85.6|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|TML [1980]|TML [198000]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|428||||428|9.02|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|428||||428|14.76|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UNICARE [2040]|UNICARE [204000]|428||||428|14.76|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|428||||428|14.76|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WEB TPA [2115]|WEB TPA [211500]|428||||428|295.32|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|428||||428|10.74|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|428||||428|21.48|295.32|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|428||||428|14.76|295.32|9.02
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AARP [1000]|AARP [100000]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA [1015]|AETNA [101529]|691.25||||691.25|311.06|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMBETTER [2930]|AMBETTER [293000]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|691.25||||691.25|345.63|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|691.25||||691.25|276.5|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|691.25||||691.25|276.5|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|691.25||||691.25|324.89|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|691.25||||691.25|283.41|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA [1260]|CIGNA PPO [126025]|691.25||||691.25|52.76|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|691.25||||691.25|345.63|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|691.25||||691.25|311.06|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|691.25||||691.25|311.06|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|691.25||||691.25|0|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|Self-pay|Self-pay|691.25||||691.25|138.25|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|TML [1980]|TML [198000]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNICARE [2040]|UNICARE [204000]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WEB TPA [2115]|WEB TPA [211500]|691.25||||691.25|476.96|476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|691.25||||691.25||476.96|52.76
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WORKER'S COMP [2125]|TML WC [212537]|691.25||||691.25||476.96|52.76
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AARP [1000]|AARP [100000]|1119.5||||1119.5|38.62|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AETNA [1015]|AETNA [101529]|1119.5||||1119.5|503.78|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AMBETTER [2930]|AMBETTER [293000]|1119.5||||1119.5|29.51|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1119.5||||1119.5|559.75|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1119.5||||1119.5|447.8|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1119.5||||1119.5|447.8|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1119.5||||1119.5|526.17|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1119.5||||1119.5|459|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA [1260]|CIGNA PPO [126025]|1119.5||||1119.5|82.35|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1119.5||||1119.5|38.62|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1119.5||||1119.5|559.75|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1119.5||||1119.5|503.78|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1119.5||||1119.5|503.78|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1119.5||||1119.5|0|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|Self-pay|Self-pay|1119.5||||1119.5|223.9|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|TML [1980]|TML [198000]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1119.5||||1119.5|23.6|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1119.5||||1119.5|38.62|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UNICARE [2040]|UNICARE [204000]|1119.5||||1119.5|38.62|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1119.5||||1119.5|38.62|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WEB TPA [2115]|WEB TPA [211500]|1119.5||||1119.5|772.46|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1119.5||||1119.5|28.1|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1119.5||||1119.5|56.2|772.46|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WORKER'S COMP [2125]|TML WC [212537]|1119.5||||1119.5|38.62|772.46|23.6
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AARP [1000]|AARP [100000]|488||||488|30.24|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA [1015]|AETNA [101529]|488||||488|219.6|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMBETTER [2930]|AMBETTER [293000]|488||||488|23.09|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|488||||488|244|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|488||||488|195.2|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|488||||488|195.2|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|488||||488|229.36|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|488||||488|200.08|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA [1260]|CIGNA PPO [126025]|488||||488|64.45|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|488||||488|30.24|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|488||||488|244|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|488||||488|219.6|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|488||||488|219.6|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|488||||488|0|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|Self-pay|Self-pay|488||||488|97.6|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|TML [1980]|TML [198000]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|488||||488|18.47|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|488||||488|30.24|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNICARE [2040]|UNICARE [204000]|488||||488|30.24|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|488||||488|30.24|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WEB TPA [2115]|WEB TPA [211500]|488||||488|336.72|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|488||||488|21.99|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|488||||488|43.98|336.72|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WORKER'S COMP [2125]|TML WC [212537]|488||||488|30.24|336.72|18.47
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AARP [1000]|AARP [100000]|97||||97|6.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA [1015]|AETNA [101529]|97||||97|43.65|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMBETTER [2930]|AMBETTER [293000]|97||||97|5.05|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|48.5|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|38.8|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|38.8|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|45.59|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|39.77|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|14.1|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97|6.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|48.5|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|43.65|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|43.65|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|0|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|Self-pay|Self-pay|97||||97|19.4|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|TML [1980]|TML [198000]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|4.04|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97|6.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNICARE [2040]|UNICARE [204000]|97||||97|6.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97|6.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97|4.81|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97|9.62|66.93|4.04
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97|6.62|66.93|4.04
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AARP [1000]|AARP [100000]|97||||97|6.69|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA [1015]|AETNA [101529]|97||||97|43.65|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMBETTER [2930]|AMBETTER [293000]|97||||97|5.31|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|48.5|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|38.8|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|38.8|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|45.59|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|39.77|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|14.27|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97|6.69|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|48.5|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|43.65|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|43.65|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|0|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|Self-pay|Self-pay|97||||97|19.4|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|TML [1980]|TML [198000]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|4.25|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97|6.69|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNICARE [2040]|UNICARE [204000]|97||||97|6.69|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97|6.69|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97|5.06|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97|10.12|66.93|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97|6.69|66.93|4.25
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AARP [1000]|AARP [100000]|573||||573|35.49|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AETNA [1015]|AETNA [101529]|573||||573|257.85|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AMBETTER [2930]|AMBETTER [293000]|573||||573|27.1|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|573||||573|286.5|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|573||||573|229.2|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|573||||573|229.2|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|573||||573|269.31|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|573||||573|234.93|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA [1260]|CIGNA PPO [126025]|573||||573|75.67|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|573||||573|35.49|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|573||||573|286.5|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|573||||573|257.85|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|573||||573|257.85|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|573||||573|0|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|Self-pay|Self-pay|573||||573|114.6|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|TML [1980]|TML [198000]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|573||||573|21.68|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|573||||573|35.49|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UNICARE [2040]|UNICARE [204000]|573||||573|35.49|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|573||||573|35.49|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WEB TPA [2115]|WEB TPA [211500]|573||||573|395.37|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|573||||573|25.81|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|573||||573|51.62|395.37|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WORKER'S COMP [2125]|TML WC [212537]|573||||573|35.49|395.37|21.68
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AARP [1000]|AARP [100000]|271||||271|29.19|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA [1015]|AETNA [101529]|271||||271|121.95|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMBETTER [2930]|AMBETTER [293000]|271||||271|22.29|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|271||||271|135.5|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271|108.4|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271|108.4|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271|127.37|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|271||||271|111.11|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA [1260]|CIGNA PPO [126025]|271||||271|62.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|271||||271|29.19|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|271||||271|135.5|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271|121.95|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271|121.95|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|0|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|Self-pay|Self-pay|271||||271|54.2|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|TML [1980]|TML [198000]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|17.83|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271|29.19|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNICARE [2040]|UNICARE [204000]|271||||271|29.19|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271|29.19|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WEB TPA [2115]|WEB TPA [211500]|271||||271|186.99|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271|21.23|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271|42.46|186.99|17.83
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WORKER'S COMP [2125]|TML WC [212537]|271||||271|29.19|186.99|17.83
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AARP [1000]|AARP [100000]|152||||152|9.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA [1015]|AETNA [101529]|152||||152|68.4|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|152||||152|7.21|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152||||152|76|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152||||152|60.8|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152||||152|60.8|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152||||152|71.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152||||152|62.32|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|152||||152|20.12|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152||||152|9.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152||||152|76|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152||||152|68.4|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152||||152|68.4|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152||||152|0|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|Self-pay|Self-pay|152||||152|30.4|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|TML [1980]|TML [198000]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152||||152|5.77|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152||||152|9.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNICARE [2040]|UNICARE [204000]|152||||152|9.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152||||152|9.44|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|152||||152|104.88|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152||||152|6.87|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|152||||152|13.74|104.88|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|152||||152|9.44|104.88|5.77
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AARP [1000]|AARP [100000]|359.25||||359.25|12.4|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA [1015]|AETNA [101529]|359.25||||359.25|161.66|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMBETTER [2930]|AMBETTER [293000]|359.25||||359.25|9.47|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|359.25||||359.25|179.63|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|359.25||||359.25|143.7|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|359.25||||359.25|143.7|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|359.25||||359.25|168.85|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|359.25||||359.25|147.29|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA [1260]|CIGNA PPO [126025]|359.25||||359.25|26.41|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|359.25||||359.25|12.4|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|359.25||||359.25|179.63|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|359.25||||359.25|161.66|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|359.25||||359.25|161.66|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|359.25||||359.25|0|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|Self-pay|Self-pay|359.25||||359.25|71.85|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|TML [1980]|TML [198000]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|359.25||||359.25|7.58|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|359.25||||359.25|12.4|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNICARE [2040]|UNICARE [204000]|359.25||||359.25|12.4|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|359.25||||359.25|12.4|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WEB TPA [2115]|WEB TPA [211500]|359.25||||359.25|247.88|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|359.25||||359.25|9.02|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|359.25||||359.25|18.04|247.88|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WORKER'S COMP [2125]|TML WC [212537]|359.25||||359.25|12.4|247.88|7.58
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AARP [1000]|AARP [100000]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AETNA [1015]|AETNA [101529]|589.25||||589.25|265.16|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AMBETTER [2930]|AMBETTER [293000]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|589.25||||589.25|294.63|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|589.25||||589.25|235.7|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|589.25||||589.25|235.7|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|589.25||||589.25|276.95|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|589.25||||589.25|241.59|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA [1260]|CIGNA PPO [126025]|589.25||||589.25|43.33|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|589.25||||589.25|294.63|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|589.25||||589.25|265.16|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|589.25||||589.25|265.16|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|589.25||||589.25|0|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|Self-pay|Self-pay|589.25||||589.25|117.85|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|TML [1980]|TML [198000]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UNICARE [2040]|UNICARE [204000]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WEB TPA [2115]|WEB TPA [211500]|589.25||||589.25|406.58|406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|589.25||||589.25||406.58|43.33
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WORKER'S COMP [2125]|TML WC [212537]|589.25||||589.25||406.58|43.33
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AARP [1000]|AARP [100000]|373||||373|23.1|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA [1015]|AETNA [101529]|373||||373|167.85|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMBETTER [2930]|AMBETTER [293000]|373||||373|17.64|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|373||||373|186.5|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|373||||373|149.2|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|373||||373|149.2|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|373||||373|175.31|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|373||||373|152.93|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA [1260]|CIGNA PPO [126025]|373||||373|49.25|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|373||||373|23.1|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|373||||373|186.5|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|373||||373|167.85|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|373||||373|167.85|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|373||||373|0|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|Self-pay|Self-pay|373||||373|74.6|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|TML [1980]|TML [198000]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|373||||373|14.11|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|373||||373|23.1|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNICARE [2040]|UNICARE [204000]|373||||373|23.1|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|373||||373|23.1|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WEB TPA [2115]|WEB TPA [211500]|373||||373|257.37|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|373||||373|16.8|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|373||||373|33.6|257.37|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WORKER'S COMP [2125]|TML WC [212537]|373||||373|23.1|257.37|14.11
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AARP [1000]|AARP [100000]|1431||||1431|69.9|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AETNA [1015]|AETNA [101529]|1431||||1431|643.95|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AMBETTER [2930]|AMBETTER [293000]|1431||||1431|53.4|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1431||||1431|715.5|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1431||||1431|572.4|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1431||||1431|572.4|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1431||||1431|672.57|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1431||||1431|586.71|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA [1260]|CIGNA PPO [126025]|1431||||1431|149.05|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1431||||1431|69.9|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1431||||1431|715.5|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1431||||1431|643.95|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1431||||1431|643.95|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1431||||1431|0|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|Self-pay|Self-pay|1431||||1431|286.2|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|TML [1980]|TML [198000]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1431||||1431|42.72|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1431||||1431|69.9|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UNICARE [2040]|UNICARE [204000]|1431||||1431|69.9|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1431||||1431|69.9|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WEB TPA [2115]|WEB TPA [211500]|1431||||1431|987.39|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1431||||1431|50.86|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1431||||1431|101.72|987.39|42.72
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WORKER'S COMP [2125]|TML WC [212537]|1431||||1431|69.9|987.39|42.72
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AARP [1000]|AARP [100000]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AETNA [1015]|AETNA [101529]|205.75||||205.75|92.59|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AMBETTER [2930]|AMBETTER [293000]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205.75||||205.75|102.88|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205.75||||205.75|82.3|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205.75||||205.75|82.3|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205.75||||205.75|96.7|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205.75||||205.75|84.36|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA [1260]|CIGNA PPO [126025]|205.75||||205.75|15.16|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205.75||||205.75|102.88|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.75||||205.75|92.59|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.75||||205.75|92.59|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205.75||||205.75|0|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|Self-pay|Self-pay|205.75||||205.75|41.15|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|TML [1980]|TML [198000]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UNICARE [2040]|UNICARE [204000]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WEB TPA [2115]|WEB TPA [211500]|205.75||||205.75|141.97|141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205.75||||205.75||141.97|15.16
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WORKER'S COMP [2125]|TML WC [212537]|205.75||||205.75||141.97|15.16
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AARP [1000]|AARP [100000]|186||||186|17.55|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA [1015]|AETNA [101529]|186||||186|83.7|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMBETTER [2930]|AMBETTER [293000]|186||||186|13.4|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|186||||186|93|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|74.4|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|74.4|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|87.42|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|186||||186|76.26|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA [1260]|CIGNA PPO [126025]|186||||186|37.4|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|186||||186|17.55|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|186||||186|93|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|83.7|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|83.7|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|0|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|Self-pay|Self-pay|186||||186|37.2|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|TML [1980]|TML [198000]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|10.72|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186|17.55|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNICARE [2040]|UNICARE [204000]|186||||186|17.55|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186|17.55|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WEB TPA [2115]|WEB TPA [211500]|186||||186|128.34|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186|12.76|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186|25.52|128.34|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WORKER'S COMP [2125]|TML WC [212537]|186||||186|17.55|128.34|10.72
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AARP [1000]|AARP [100000]|229.25||||229.25|7.9|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA [1015]|AETNA [101529]|229.25||||229.25|103.16|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMBETTER [2930]|AMBETTER [293000]|229.25||||229.25|6.03|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|229.25||||229.25|114.63|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|229.25||||229.25|91.7|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|229.25||||229.25|91.7|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|229.25||||229.25|107.75|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|229.25||||229.25|93.99|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA [1260]|CIGNA PPO [126025]|229.25||||229.25|16.85|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|229.25||||229.25|7.9|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|229.25||||229.25|114.63|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|229.25||||229.25|103.16|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|229.25||||229.25|103.16|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|229.25||||229.25|0|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|Self-pay|Self-pay|229.25||||229.25|45.85|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|TML [1980]|TML [198000]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|229.25||||229.25|4.82|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|229.25||||229.25|7.9|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNICARE [2040]|UNICARE [204000]|229.25||||229.25|7.9|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|229.25||||229.25|7.9|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WEB TPA [2115]|WEB TPA [211500]|229.25||||229.25|158.18|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|229.25||||229.25|5.74|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|229.25||||229.25|11.48|158.18|4.82
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WORKER'S COMP [2125]|TML WC [212537]|229.25||||229.25|7.9|158.18|4.82
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AARP [1000]|AARP [100000]|257.75||||257.75|8.89|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA [1015]|AETNA [101529]|257.75||||257.75|115.99|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMBETTER [2930]|AMBETTER [293000]|257.75||||257.75|6.79|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|257.75||||257.75|128.88|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|257.75||||257.75|103.1|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|257.75||||257.75|103.1|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|257.75||||257.75|121.14|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|257.75||||257.75|105.68|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA [1260]|CIGNA PPO [126025]|257.75||||257.75|18.97|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|257.75||||257.75|8.89|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|257.75||||257.75|128.88|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|257.75||||257.75|115.99|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|257.75||||257.75|115.99|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|257.75||||257.75|0|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|Self-pay|Self-pay|257.75||||257.75|51.55|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|TML [1980]|TML [198000]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|257.75||||257.75|5.43|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|257.75||||257.75|8.89|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNICARE [2040]|UNICARE [204000]|257.75||||257.75|8.89|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|257.75||||257.75|8.89|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WEB TPA [2115]|WEB TPA [211500]|257.75||||257.75|177.85|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|257.75||||257.75|6.47|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|257.75||||257.75|12.94|177.85|5.43
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WORKER'S COMP [2125]|TML WC [212537]|257.75||||257.75|8.89|177.85|5.43
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AARP [1000]|AARP [100000]|315||||315|19.49|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA [1015]|AETNA [101529]|315||||315|141.75|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|315||||315|14.89|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|315||||315|157.5|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|315||||315|126|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|315||||315|126|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|315||||315|148.05|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|315||||315|129.15|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|315||||315|41.54|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|315||||315|19.49|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|315||||315|157.5|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|315||||315|141.75|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|315||||315|141.75|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|315||||315|0|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|Self-pay|Self-pay|315||||315|63|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|TML [1980]|TML [198000]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|315||||315|11.91|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|315||||315|19.49|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNICARE [2040]|UNICARE [204000]|315||||315|19.49|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|315||||315|19.49|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|315||||315|217.35|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|315||||315|14.18|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|315||||315|28.36|217.35|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|315||||315|19.49|217.35|11.91
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AARP [1000]|AARP [100000]|675.25||||675.25|23.29|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA [1015]|AETNA [101529]|675.25||||675.25|303.86|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMBETTER [2930]|AMBETTER [293000]|675.25||||675.25|17.79|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|675.25||||675.25|337.63|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|675.25||||675.25|270.1|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|675.25||||675.25|270.1|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|675.25||||675.25|317.37|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|675.25||||675.25|276.85|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA [1260]|CIGNA PPO [126025]|675.25||||675.25|49.65|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|675.25||||675.25|23.29|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|675.25||||675.25|337.63|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|675.25||||675.25|303.86|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|675.25||||675.25|303.86|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|675.25||||675.25|0|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|Self-pay|Self-pay|675.25||||675.25|135.05|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|TML [1980]|TML [198000]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|675.25||||675.25|14.23|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|675.25||||675.25|23.29|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNICARE [2040]|UNICARE [204000]|675.25||||675.25|23.29|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|675.25||||675.25|23.29|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WEB TPA [2115]|WEB TPA [211500]|675.25||||675.25|465.92|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|675.25||||675.25|16.94|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|675.25||||675.25|33.88|465.92|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WORKER'S COMP [2125]|TML WC [212537]|675.25||||675.25|23.29|465.92|14.23
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AARP [1000]|AARP [100000]|199||||199|13.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA [1015]|AETNA [101529]|199||||199|89.55|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMBETTER [2930]|AMBETTER [293000]|199||||199|13.09|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|199||||199|99.5|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|199||||199|79.6|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|199||||199|79.6|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|199||||199|93.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|199||||199|81.59|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA [1260]|CIGNA PPO [126025]|199||||199|28.83|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|199||||199|13.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|199||||199|99.5|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|199||||199|89.55|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|199||||199|89.55|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|199||||199|0|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|Self-pay|Self-pay|199||||199|39.8|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|TML [1980]|TML [198000]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|199||||199|10.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|199||||199|13.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNICARE [2040]|UNICARE [204000]|199||||199|13.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|199||||199|13.53|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WEB TPA [2115]|WEB TPA [211500]|199||||199|137.31|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|199||||199|12.47|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|199||||199|24.94|137.31|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WORKER'S COMP [2125]|TML WC [212537]|199||||199|13.53|137.31|10.47
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AARP [1000]|AARP [100000]|1249||||1249|5.43|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA [1015]|AETNA [101529]|1249||||1249|562.05|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMBETTER [2930]|AMBETTER [293000]|1249||||1249|4.15|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1249||||1249|624.5|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1249||||1249|499.6|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1249||||1249|499.6|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1249||||1249|587.03|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1249||||1249|512.09|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA [1260]|CIGNA PPO [126025]|1249||||1249|11.59|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1249||||1249|5.43|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1249||||1249|624.5|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1249||||1249|562.05|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1249||||1249|562.05|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1249||||1249|0|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|Self-pay|Self-pay|1249||||1249|249.8|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|TML [1980]|TML [198000]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1249||||1249|3.32|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1249||||1249|5.43|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNICARE [2040]|UNICARE [204000]|1249||||1249|5.43|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1249||||1249|5.43|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WEB TPA [2115]|WEB TPA [211500]|1249||||1249|861.81|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1249||||1249|3.95|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1249||||1249|7.9|861.81|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WORKER'S COMP [2125]|TML WC [212537]|1249||||1249|5.43|861.81|3.32
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AARP [1000]|AARP [100000]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA [1015]|AETNA [101529]|96||||96|43.2|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMBETTER [2930]|AMBETTER [293000]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|96||||96|48|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|38.4|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|38.4|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|45.12|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|96||||96|39.36|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA [1260]|CIGNA PPO [126025]|96||||96|13.94|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|96||||96|48|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|43.2|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|43.2|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96|0|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|Self-pay|Self-pay|96||||96|19.2|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|TML [1980]|TML [198000]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNICARE [2040]|UNICARE [204000]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WEB TPA [2115]|WEB TPA [211500]|96||||96|66.24|66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96||66.24|13.94
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WORKER'S COMP [2125]|TML WC [212537]|96||||96||66.24|13.94
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AARP [1000]|AARP [100000]|91||||91|6.21|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA [1015]|AETNA [101529]|91||||91|40.95|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMBETTER [2930]|AMBETTER [293000]|91||||91|4.75|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|91||||91|45.5|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|91||||91|36.4|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91||||91|36.4|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|91||||91|42.77|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|91||||91|37.31|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA [1260]|CIGNA PPO [126025]|91||||91|13.24|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|91||||91|6.21|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|91||||91|45.5|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91||||91|40.95|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91||||91|40.95|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91||||91|0|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|Self-pay|Self-pay|91||||91|18.2|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|TML [1980]|TML [198000]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|91||||91|3.8|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91||||91|6.21|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNICARE [2040]|UNICARE [204000]|91||||91|6.21|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91||||91|6.21|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WEB TPA [2115]|WEB TPA [211500]|91||||91|62.79|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91||||91|4.52|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|91||||91|9.04|62.79|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WORKER'S COMP [2125]|TML WC [212537]|91||||91|6.21|62.79|3.8
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AARP [1000]|AARP [100000]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|85.16|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|94.63|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|75.7|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|75.7|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|88.95|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|77.59|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.94|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|94.63|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|85.16|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|85.16|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25|0|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|Self-pay|Self-pay|189.25||||189.25|37.85|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.25||||189.25||130.58|13.94
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25||130.58|13.94
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AARP [1000]|AARP [100000]|462||||462|15.95|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA [1015]|AETNA [101529]|462||||462|207.9|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMBETTER [2930]|AMBETTER [293000]|462||||462|12.19|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|462||||462|231|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|462||||462|184.8|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|462||||462|184.8|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|462||||462|217.14|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|462||||462|189.42|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA [1260]|CIGNA PPO [126025]|462||||462|34.03|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|462||||462|15.95|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|462||||462|231|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|462||||462|207.9|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|462||||462|207.9|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|462||||462|0|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|Self-pay|Self-pay|462||||462|92.4|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|TML [1980]|TML [198000]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|462||||462|9.75|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|462||||462|15.95|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNICARE [2040]|UNICARE [204000]|462||||462|15.95|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|462||||462|15.95|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WEB TPA [2115]|WEB TPA [211500]|462||||462|318.78|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|462||||462|11.61|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|462||||462|23.22|318.78|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WORKER'S COMP [2125]|TML WC [212537]|462||||462|15.95|318.78|9.75
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AARP [1000]|AARP [100000]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA [1015]|AETNA [101529]|264.25||||264.25|118.91|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMBETTER [2930]|AMBETTER [293000]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264.25||||264.25|132.13|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264.25||||264.25|105.7|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264.25||||264.25|105.7|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264.25||||264.25|124.2|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264.25||||264.25|108.34|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA [1260]|CIGNA PPO [126025]|264.25||||264.25|40.22|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264.25||||264.25|132.13|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264.25||||264.25|118.91|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264.25||||264.25|118.91|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264.25||||264.25|0|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|Self-pay|Self-pay|264.25||||264.25|52.85|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|TML [1980]|TML [198000]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNICARE [2040]|UNICARE [204000]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WEB TPA [2115]|WEB TPA [211500]|264.25||||264.25|182.33|182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264.25||||264.25||182.33|40.22
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WORKER'S COMP [2125]|TML WC [212537]|264.25||||264.25||182.33|40.22
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AARP [1000]|AARP [100000]|230||||230|15.65|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AETNA [1015]|AETNA [101529]|230||||230|103.5|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AMBETTER [2930]|AMBETTER [293000]|230||||230|11.96|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|230||||230|115|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|230||||230|92|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|230||||230|92|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|230||||230|108.1|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|230||||230|94.3|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA [1260]|CIGNA PPO [126025]|230||||230|33.36|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|230||||230|15.65|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|230||||230|115|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|230||||230|103.5|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|230||||230|103.5|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|230||||230|0|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|Self-pay|Self-pay|230||||230|46|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|TML [1980]|TML [198000]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|230||||230|9.57|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|230||||230|15.65|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UNICARE [2040]|UNICARE [204000]|230||||230|15.65|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|230||||230|15.65|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WEB TPA [2115]|WEB TPA [211500]|230||||230|158.7|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|230||||230|11.39|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|230||||230|22.78|158.7|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WORKER'S COMP [2125]|TML WC [212537]|230||||230|15.65|158.7|9.57
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AARP [1000]|AARP [100000]|152||||152|10.33|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA [1015]|AETNA [101529]|152||||152|68.4|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMBETTER [2930]|AMBETTER [293000]|152||||152|7.9|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152||||152|76|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152||||152|60.8|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152||||152|60.8|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152||||152|71.44|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152||||152|62.32|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA [1260]|CIGNA PPO [126025]|152||||152|22.04|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152||||152|10.33|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152||||152|76|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152||||152|68.4|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152||||152|68.4|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152||||152|0|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|Self-pay|Self-pay|152||||152|30.4|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|TML [1980]|TML [198000]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152||||152|6.32|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152||||152|10.33|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNICARE [2040]|UNICARE [204000]|152||||152|10.33|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152||||152|10.33|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WEB TPA [2115]|WEB TPA [211500]|152||||152|104.88|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152||||152|7.52|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|152||||152|15.04|104.88|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WORKER'S COMP [2125]|TML WC [212537]|152||||152|10.33|104.88|6.32
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AARP [1000]|AARP [100000]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA [1015]|AETNA [101529]|737||||737|331.65|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMBETTER [2930]|AMBETTER [293000]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|737||||737|368.5|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|737||||737|294.8|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|737||||737|294.8|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|737||||737|346.39|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|737||||737|302.17|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA [1260]|CIGNA PPO [126025]|737||||737|42.04|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|737||||737|368.5|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|737||||737|331.65|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|737||||737|331.65|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|737||||737|0|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|Self-pay|Self-pay|737||||737|147.4|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|TML [1980]|TML [198000]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|737||||737|103.18|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNICARE [2040]|UNICARE [204000]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WEB TPA [2115]|WEB TPA [211500]|737||||737|508.53|508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|737||||737||508.53|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WORKER'S COMP [2125]|TML WC [212537]|737||||737||508.53|42.04
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AARP [1000]|AARP [100000]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA [1015]|AETNA [101529]|390||||390|175.5|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMBETTER [2930]|AMBETTER [293000]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|390||||390|195|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|390||||390|156|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|390||||390|156|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|390||||390|183.3|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|390||||390|159.9|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA [1260]|CIGNA PPO [126025]|390||||390|53.82|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|390||||390|195|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|390||||390|175.5|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|390||||390|175.5|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|390||||390|0|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|Self-pay|Self-pay|390||||390|78|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|TML [1980]|TML [198000]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNICARE [2040]|UNICARE [204000]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WEB TPA [2115]|WEB TPA [211500]|390||||390|269.1|269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|390||||390||269.1|53.82
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WORKER'S COMP [2125]|TML WC [212537]|390||||390||269.1|53.82
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AARP [1000]|AARP [100000]|481.75||||481.75|16.62|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA [1015]|AETNA [101529]|481.75||||481.75|216.79|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMBETTER [2930]|AMBETTER [293000]|481.75||||481.75|12.69|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|481.75||||481.75|240.88|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|481.75||||481.75|192.7|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|481.75||||481.75|192.7|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|481.75||||481.75|226.42|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|481.75||||481.75|197.52|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA [1260]|CIGNA PPO [126025]|481.75||||481.75|35.45|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|481.75||||481.75|16.62|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|481.75||||481.75|240.88|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|481.75||||481.75|216.79|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|481.75||||481.75|216.79|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|481.75||||481.75|0|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|Self-pay|Self-pay|481.75||||481.75|96.35|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|TML [1980]|TML [198000]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|481.75||||481.75|10.16|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|481.75||||481.75|16.62|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNICARE [2040]|UNICARE [204000]|481.75||||481.75|16.62|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|481.75||||481.75|16.62|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WEB TPA [2115]|WEB TPA [211500]|481.75||||481.75|332.41|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|481.75||||481.75|12.09|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|481.75||||481.75|24.18|332.41|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WORKER'S COMP [2125]|TML WC [212537]|481.75||||481.75|16.62|332.41|10.16
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AARP [1000]|AARP [100000]|279.45||||279.45|6.5|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA [1015]|AETNA [101529]|279.45||||279.45|125.75|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMBETTER [2930]|AMBETTER [293000]|279.45||||279.45|4.96|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|279.45||||279.45|139.73|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|279.45||||279.45|111.78|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|279.45||||279.45|111.78|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|279.45||||279.45|131.34|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|279.45||||279.45|114.57|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA [1260]|CIGNA PPO [126025]|279.45||||279.45|13.87|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|279.45||||279.45|6.5|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|279.45||||279.45|139.73|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|279.45||||279.45|125.75|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|279.45||||279.45|125.75|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|279.45||||279.45|0|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|Self-pay|Self-pay|279.45||||279.45|55.89|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|TML [1980]|TML [198000]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|279.45||||279.45|39.12|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|279.45||||279.45|6.5|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNICARE [2040]|UNICARE [204000]|279.45||||279.45|6.5|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|279.45||||279.45|6.5|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WEB TPA [2115]|WEB TPA [211500]|279.45||||279.45|192.82|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|279.45||||279.45|4.72|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|279.45||||279.45|9.44|192.82|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WORKER'S COMP [2125]|TML WC [212537]|279.45||||279.45|6.5|192.82|4.72
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AARP [1000]|AARP [100000]|243||||243|7.57|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA [1015]|AETNA [101529]|243||||243|109.35|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMBETTER [2930]|AMBETTER [293000]|243||||243|5.88|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|243||||243|121.5|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|243||||243|97.2|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|243||||243|97.2|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|243||||243|114.21|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|243||||243|99.63|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|243||||243|16.15|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|243||||243|7.57|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|243||||243|121.5|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243||||243|109.35|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|243||||243|109.35|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|243||||243|0|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|Self-pay|Self-pay|243||||243|48.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|TML [1980]|TML [198000]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|243||||243|34.02|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|243||||243|7.57|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNICARE [2040]|UNICARE [204000]|243||||243|7.57|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|243||||243|7.57|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WEB TPA [2115]|WEB TPA [211500]|243||||243|167.67|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|243||||243|5.6|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|243||||243|11.2|167.67|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|243||||243|7.57|167.67|5.6
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AARP [1000]|AARP [100000]|136.62||||136.62|5.87|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA [1015]|AETNA [101529]|136.62||||136.62|61.48|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMBETTER [2930]|AMBETTER [293000]|136.62||||136.62|4.48|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|136.62||||136.62|68.31|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.62||||136.62|54.65|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.62||||136.62|54.65|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.62||||136.62|64.21|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|136.62||||136.62|56.01|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA [1260]|CIGNA PPO [126025]|136.62||||136.62|12.51|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|136.62||||136.62|5.87|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|136.62||||136.62|68.31|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.62||||136.62|61.48|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.62||||136.62|61.48|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.62||||136.62|0|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|Self-pay|Self-pay|136.62||||136.62|27.32|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|TML [1980]|TML [198000]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.62||||136.62|19.13|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.62||||136.62|5.87|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNICARE [2040]|UNICARE [204000]|136.62||||136.62|5.87|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.62||||136.62|5.87|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WEB TPA [2115]|WEB TPA [211500]|136.62||||136.62|94.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.62||||136.62|4.27|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.62||||136.62|8.54|94.27|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WORKER'S COMP [2125]|TML WC [212537]|136.62||||136.62|5.87|94.27|4.27
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AARP [1000]|AARP [100000]|367||||367|9.83|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA [1015]|AETNA [101529]|367||||367|165.15|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMBETTER [2930]|AMBETTER [293000]|367||||367|7.7|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|367||||367|183.5|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|367||||367|146.8|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|367||||367|146.8|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|367||||367|172.49|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|367||||367|150.47|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA [1260]|CIGNA PPO [126025]|367||||367|20.99|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|367||||367|9.83|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|367||||367|183.5|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|367||||367|165.15|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|367||||367|165.15|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|367||||367|0|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|Self-pay|Self-pay|367||||367|73.4|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|TML [1980]|TML [198000]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|367||||367|51.38|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|367||||367|9.83|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNICARE [2040]|UNICARE [204000]|367||||367|9.83|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|367||||367|9.83|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WEB TPA [2115]|WEB TPA [211500]|367||||367|253.23|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|367||||367|7.33|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|367||||367|14.66|253.23|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WORKER'S COMP [2125]|TML WC [212537]|367||||367|9.83|253.23|7.33
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AARP [1000]|AARP [100000]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA [1015]|AETNA [101529]|299.64||||299.64|134.84|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMBETTER [2930]|AMBETTER [293000]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|299.64||||299.64|149.82|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299.64||||299.64|119.86|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299.64||||299.64|119.86|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299.64||||299.64|140.83|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|299.64||||299.64|122.85|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA [1260]|CIGNA PPO [126025]|299.64||||299.64|13.94|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|299.64||||299.64|149.82|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299.64||||299.64|134.84|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299.64||||299.64|134.84|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299.64||||299.64|0|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|Self-pay|Self-pay|299.64||||299.64|59.93|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|TML [1980]|TML [198000]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299.64||||299.64|41.95|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNICARE [2040]|UNICARE [204000]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WEB TPA [2115]|WEB TPA [211500]|299.64||||299.64|206.75|206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299.64||||299.64||206.75|13.94
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WORKER'S COMP [2125]|TML WC [212537]|299.64||||299.64||206.75|13.94
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AARP [1000]|AARP [100000]|102||||102|7.11|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA [1015]|AETNA [101529]|102||||102|45.9|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMBETTER [2930]|AMBETTER [293000]|102||||102|5.44|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|102||||102|51|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|40.8|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|40.8|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|47.94|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|102||||102|41.82|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA [1260]|CIGNA PPO [126025]|102||||102|15.16|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|102||||102|7.11|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|102||||102|51|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|45.9|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|45.9|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|0|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|Self-pay|Self-pay|102||||102|20.4|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|TML [1980]|TML [198000]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|4.35|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102|7.11|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNICARE [2040]|UNICARE [204000]|102||||102|7.11|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102|7.11|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WEB TPA [2115]|WEB TPA [211500]|102||||102|70.38|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102|5.18|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102|10.36|70.38|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WORKER'S COMP [2125]|TML WC [212537]|102||||102|7.11|70.38|4.35
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AARP [1000]|AARP [100000]|506||||506|17.8|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA [1015]|AETNA [101529]|506||||506|227.7|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMBETTER [2930]|AMBETTER [293000]|506||||506|13.6|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|506||||506|253|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|506||||506|202.4|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|506||||506|202.4|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|506||||506|237.82|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|506||||506|207.46|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA [1260]|CIGNA PPO [126025]|506||||506|37.93|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|506||||506|17.8|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|506||||506|253|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|506||||506|227.7|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|506||||506|227.7|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|506||||506|0|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|Self-pay|Self-pay|506||||506|101.2|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|TML [1980]|TML [198000]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|506||||506|10.88|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|506||||506|17.8|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNICARE [2040]|UNICARE [204000]|506||||506|17.8|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|506||||506|17.8|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WEB TPA [2115]|WEB TPA [211500]|506||||506|349.14|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|506||||506|12.95|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|506||||506|25.9|349.14|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WORKER'S COMP [2125]|TML WC [212537]|506||||506|17.8|349.14|10.88
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AARP [1000]|AARP [100000]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA [1015]|AETNA [101529]|829.25||||829.25|373.16|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMBETTER [2930]|AMBETTER [293000]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|829.25||||829.25|414.63|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|829.25||||829.25|331.7|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|829.25||||829.25|331.7|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|829.25||||829.25|389.75|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|829.25||||829.25|339.99|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA [1260]|CIGNA PPO [126025]|829.25||||829.25|74.57|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|829.25||||829.25|414.63|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|829.25||||829.25|373.16|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|829.25||||829.25|373.16|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|829.25||||829.25|0|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|Self-pay|Self-pay|829.25||||829.25|165.85|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|TML [1980]|TML [198000]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNICARE [2040]|UNICARE [204000]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WEB TPA [2115]|WEB TPA [211500]|829.25||||829.25|572.18|572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|829.25||||829.25||572.18|74.57
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WORKER'S COMP [2125]|TML WC [212537]|829.25||||829.25||572.18|74.57
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AARP [1000]|AARP [100000]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AETNA [1015]|AETNA [101529]|236||||236|106.2|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|236||||236|118|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|94.4|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|94.4|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|110.92|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|236||||236|96.76|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|236||||236|35.19|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|236||||236|118|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|106.2|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|106.2|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|0|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|Self-pay|Self-pay|236||||236|47.2|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|TML [1980]|TML [198000]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|236||||236|162.84|162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236||162.84|35.19
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|236||||236||162.84|35.19
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AARP [1000]|AARP [100000]|516||||516|17.8|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AETNA [1015]|AETNA [101529]|516||||516|232.2|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AMBETTER [2930]|AMBETTER [293000]|516||||516|13.6|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|516||||516|258|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|516||||516|206.4|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|516||||516|206.4|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|516||||516|242.52|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|516||||516|211.56|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA [1260]|CIGNA PPO [126025]|516||||516|37.93|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|516||||516|17.8|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|516||||516|258|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|516||||516|232.2|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|516||||516|232.2|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|516||||516|0|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|Self-pay|Self-pay|516||||516|103.2|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|TML [1980]|TML [198000]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|516||||516|10.88|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|516||||516|17.8|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UNICARE [2040]|UNICARE [204000]|516||||516|17.8|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|516||||516|17.8|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WEB TPA [2115]|WEB TPA [211500]|516||||516|356.04|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|516||||516|12.95|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|516||||516|25.9|356.04|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WORKER'S COMP [2125]|TML WC [212537]|516||||516|17.8|356.04|10.88
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AARP [1000]|AARP [100000]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA [1015]|AETNA [101529]|714.75||||714.75|321.64|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|714.75||||714.75|357.38|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|714.75||||714.75|285.9|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|714.75||||714.75|285.9|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|714.75||||714.75|335.93|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|714.75||||714.75|293.05|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|714.75||||714.75|35.32|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|714.75||||714.75|357.38|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|714.75||||714.75|321.64|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|714.75||||714.75|321.64|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|714.75||||714.75|0|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|Self-pay|Self-pay|714.75||||714.75|142.95|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|TML [1980]|TML [198000]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNICARE [2040]|UNICARE [204000]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|714.75||||714.75|493.18|493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|714.75||||714.75||493.18|35.32
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|714.75||||714.75||493.18|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AARP [1000]|AARP [100000]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA [1015]|AETNA [101529]|1007.75||||1007.75|453.49|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMBETTER [2930]|AMBETTER [293000]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1007.75||||1007.75|503.88|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1007.75||||1007.75|403.1|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1007.75||||1007.75|403.1|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1007.75||||1007.75|473.64|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1007.75||||1007.75|413.18|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA [1260]|CIGNA PPO [126025]|1007.75||||1007.75|35.32|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1007.75||||1007.75|503.88|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1007.75||||1007.75|453.49|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1007.75||||1007.75|453.49|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1007.75||||1007.75|0|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|Self-pay|Self-pay|1007.75||||1007.75|201.55|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|TML [1980]|TML [198000]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNICARE [2040]|UNICARE [204000]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WEB TPA [2115]|WEB TPA [211500]|1007.75||||1007.75|695.35|695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1007.75||||1007.75||695.35|35.32
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WORKER'S COMP [2125]|TML WC [212537]|1007.75||||1007.75||695.35|35.32
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AARP [1000]|AARP [100000]|68||||68|30.71|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AETNA [1015]|AETNA [101529]|68||||68|30.6|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AMBETTER [2930]|AMBETTER [293000]|68||||68|23.46|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|68||||68|34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68||||68|27.2|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68||||68|27.2|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68||||68|31.96|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|68||||68|27.88|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA [1260]|CIGNA PPO [126025]|68||||68|65.5|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|68||||68|30.71|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|68||||68|34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68||||68|30.6|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68||||68|30.6|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68||||68|0|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|Self-pay|Self-pay|68||||68|13.6|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|TML [1980]|TML [198000]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68||||68|18.77|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68||||68|30.71|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UNICARE [2040]|UNICARE [204000]|68||||68|30.71|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68||||68|30.71|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WEB TPA [2115]|WEB TPA [211500]|68||||68|46.92|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68||||68|22.34|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68||||68|44.68|65.5|13.6
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WORKER'S COMP [2125]|TML WC [212537]|68||||68|30.71|65.5|13.6
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AARP [1000]|AARP [100000]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AETNA [1015]|AETNA [101529]|600.5||||600.5|270.23|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AMBETTER [2930]|AMBETTER [293000]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|600.5||||600.5|300.25|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600.5||||600.5|240.2|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600.5||||600.5|240.2|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600.5||||600.5|282.24|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|600.5||||600.5|246.21|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA [1260]|CIGNA PPO [126025]|600.5||||600.5|44.19|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|600.5||||600.5|300.25|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600.5||||600.5|270.23|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600.5||||600.5|270.23|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600.5||||600.5|0|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|Self-pay|Self-pay|600.5||||600.5|120.1|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|TML [1980]|TML [198000]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UNICARE [2040]|UNICARE [204000]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WEB TPA [2115]|WEB TPA [211500]|600.5||||600.5|414.35|414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600.5||||600.5||414.35|44.19
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WORKER'S COMP [2125]|TML WC [212537]|600.5||||600.5||414.35|44.19
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AARP [1000]|AARP [100000]|664.5||||664.5|27.2|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA [1015]|AETNA [101529]|664.5||||664.5|299.03|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMBETTER [2930]|AMBETTER [293000]|664.5||||664.5|24.75|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|664.5||||664.5|332.25|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|664.5||||664.5|265.8|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|664.5||||664.5|265.8|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|664.5||||664.5|312.32|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|664.5||||664.5|272.45|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA [1260]|CIGNA PPO [126025]|664.5||||664.5|57.99|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|664.5||||664.5|27.2|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|664.5||||664.5|332.25|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|664.5||||664.5|299.03|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|664.5||||664.5|299.03|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|664.5||||664.5|0|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|Self-pay|Self-pay|664.5||||664.5|132.9|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|TML [1980]|TML [198000]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|664.5||||664.5|19.8|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|664.5||||664.5|27.2|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNICARE [2040]|UNICARE [204000]|664.5||||664.5|27.2|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|664.5||||664.5|27.2|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WEB TPA [2115]|WEB TPA [211500]|664.5||||664.5|458.51|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|664.5||||664.5|23.57|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|664.5||||664.5|47.14|458.51|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WORKER'S COMP [2125]|TML WC [212537]|664.5||||664.5|27.2|458.51|19.8
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AARP [1000]|AARP [100000]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|29.86|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25||329.99|29.86
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||329.99|29.86
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AARP [1000]|AARP [100000]|111||||111|7.8|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AETNA [1015]|AETNA [101529]|111||||111|49.95|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMBETTER [2930]|AMBETTER [293000]|111||||111|6.45|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|111||||111|55.5|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111||||111|44.4|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111||||111|44.4|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111||||111|52.17|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|111||||111|45.51|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA [1260]|CIGNA PPO [126025]|111||||111|16.62|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|111||||111|7.8|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|111||||111|55.5|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111||||111|49.95|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111||||111|49.95|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111||||111|0|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|Self-pay|Self-pay|111||||111|22.2|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|TML [1980]|TML [198000]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111||||111|5.16|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111||||111|7.8|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UNICARE [2040]|UNICARE [204000]|111||||111|7.8|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111||||111|7.8|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WEB TPA [2115]|WEB TPA [211500]|111||||111|76.59|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111||||111|6.14|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111||||111|12.28|76.59|5.16
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WORKER'S COMP [2125]|TML WC [212537]|111||||111|7.8|76.59|5.16
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AARP [1000]|AARP [100000]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA [1015]|AETNA [101529]|16||||16|7.2|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMBETTER [2930]|AMBETTER [293000]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16||||16|8|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16||||16|6.4|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16||||16|6.4|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16||||16|7.52|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16||||16|6.56|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA [1260]|CIGNA PPO [126025]|16||||16|16|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16||||16|8|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16||||16|7.2|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16||||16|7.2|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16||||16|0|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|Self-pay|Self-pay|16||||16|3.2|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|TML [1980]|TML [198000]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16||||16|2.24|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNICARE [2040]|UNICARE [204000]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WEB TPA [2115]|WEB TPA [211500]|16||||16|11.04|16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16||||16||16|2.24
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WORKER'S COMP [2125]|TML WC [212537]|16||||16||16|2.24
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AARP [1000]|AARP [100000]|84||||84|5.87|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA [1015]|AETNA [101529]|84||||84|37.8|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMBETTER [2930]|AMBETTER [293000]|84||||84|4.48|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84||||84|42|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84||||84|33.6|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84||||84|33.6|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84||||84|39.48|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84||||84|34.44|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA [1260]|CIGNA PPO [126025]|84||||84|12.51|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84||||84|5.87|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84||||84|42|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84||||84|37.8|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84||||84|37.8|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84||||84|0|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|Self-pay|Self-pay|84||||84|16.8|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|TML [1980]|TML [198000]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84||||84|3.59|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84||||84|5.87|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNICARE [2040]|UNICARE [204000]|84||||84|5.87|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84||||84|5.87|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WEB TPA [2115]|WEB TPA [211500]|84||||84|57.96|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84||||84|4.27|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84||||84|8.54|57.96|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WORKER'S COMP [2125]|TML WC [212537]|84||||84|5.87|57.96|3.59
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AARP [1000]|AARP [100000]|326||||326|13.99|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|10.69|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|29.86|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326|13.99|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|Self-pay|Self-pay|326||||326|65.2|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326|8.55|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326|13.99|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNICARE [2040]|UNICARE [204000]|326||||326|13.99|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326|13.99|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|10.18|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|20.36|224.94|8.55
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326|13.99|224.94|8.55
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AARP [1000]|AARP [100000]|678.75||||678.75|23.41|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA [1015]|AETNA [101529]|678.75||||678.75|305.44|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMBETTER [2930]|AMBETTER [293000]|678.75||||678.75|17.88|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|678.75||||678.75|339.38|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|678.75||||678.75|271.5|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|678.75||||678.75|271.5|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|678.75||||678.75|319.01|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|678.75||||678.75|278.29|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA [1260]|CIGNA PPO [126025]|678.75||||678.75|49.91|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|678.75||||678.75|23.41|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|678.75||||678.75|339.38|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|678.75||||678.75|305.44|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|678.75||||678.75|305.44|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|678.75||||678.75|0|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|Self-pay|Self-pay|678.75||||678.75|135.75|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|TML [1980]|TML [198000]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|678.75||||678.75|14.31|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|678.75||||678.75|23.41|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNICARE [2040]|UNICARE [204000]|678.75||||678.75|23.41|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|678.75||||678.75|23.41|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WEB TPA [2115]|WEB TPA [211500]|678.75||||678.75|468.34|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|678.75||||678.75|17.03|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|678.75||||678.75|34.06|468.34|14.31
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WORKER'S COMP [2125]|TML WC [212537]|678.75||||678.75|23.41|468.34|14.31
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AARP [1000]|AARP [100000]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AMBETTER [2930]|AMBETTER [293000]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|34.66|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|Self-pay|Self-pay|326||||326|65.2|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UNICARE [2040]|UNICARE [204000]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326||224.94|34.66
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||224.94|34.66
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AARP [1000]|AARP [100000]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AMBETTER [2930]|AMBETTER [293000]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|37.17|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|Self-pay|Self-pay|326||||326|65.2|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UNICARE [2040]|UNICARE [204000]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326||224.94|37.17
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||224.94|37.17
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AARP [1000]|AARP [100000]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMBETTER [2930]|AMBETTER [293000]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|33.63|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|Self-pay|Self-pay|326||||326|65.2|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNICARE [2040]|UNICARE [204000]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326||224.94|33.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||224.94|33.63
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AARP [1000]|AARP [100000]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA [1015]|AETNA [101529]|823||||823|370.35|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMBETTER [2930]|AMBETTER [293000]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|823||||823|411.5|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|823||||823|329.2|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|823||||823|329.2|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|823||||823|386.81|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|823||||823|337.43|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA [1260]|CIGNA PPO [126025]|823||||823|35.52|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|823||||823|411.5|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|823||||823|370.35|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|823||||823|370.35|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|823||||823|0|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|Self-pay|Self-pay|823||||823|164.6|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|TML [1980]|TML [198000]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNICARE [2040]|UNICARE [204000]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WEB TPA [2115]|WEB TPA [211500]|823||||823|567.87|567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|823||||823||567.87|35.52
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WORKER'S COMP [2125]|TML WC [212537]|823||||823||567.87|35.52
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AARP [1000]|AARP [100000]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AMBETTER [2930]|AMBETTER [293000]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|35.91|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|Self-pay|Self-pay|326||||326|65.2|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UNICARE [2040]|UNICARE [204000]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326||224.94|35.91
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||224.94|35.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AARP [1000]|AARP [100000]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA [1015]|AETNA [101529]|326||||326|146.7|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMBETTER [2930]|AMBETTER [293000]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|163|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|130.4|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|130.4|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|153.22|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|133.66|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|38.13|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|163|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|146.7|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|146.7|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|0|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|Self-pay|Self-pay|326||||326|65.2|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|TML [1980]|TML [198000]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNICARE [2040]|UNICARE [204000]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326||224.94|38.13
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||224.94|38.13
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AARP [1000]|AARP [100000]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA [1015]|AETNA [101529]|983.94||||983.94|442.77|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMBETTER [2930]|AMBETTER [293000]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|983.94||||983.94|491.97|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|983.94||||983.94|393.58|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|983.94||||983.94|393.58|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|983.94||||983.94|462.45|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|983.94||||983.94|403.42|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA [1260]|CIGNA PPO [126025]|983.94||||983.94|26.05|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|983.94||||983.94|491.97|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|983.94||||983.94|442.77|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|983.94||||983.94|442.77|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|983.94||||983.94|0|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|Self-pay|Self-pay|983.94||||983.94|196.79|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|TML [1980]|TML [198000]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNICARE [2040]|UNICARE [204000]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WEB TPA [2115]|WEB TPA [211500]|983.94||||983.94|678.92|678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|983.94||||983.94||678.92|26.05
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WORKER'S COMP [2125]|TML WC [212537]|983.94||||983.94||678.92|26.05
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AARP [1000]|AARP [100000]|261||||261|16.57|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA [1015]|AETNA [101529]|261||||261|117.45|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|261||||261|12.65|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|261||||261|130.5|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261||||261|104.4|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261||||261|104.4|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261||||261|122.67|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|261||||261|107.01|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|261||||261|35.32|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|261||||261|16.57|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|261||||261|130.5|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261||||261|117.45|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261||||261|117.45|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261||||261|0|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|Self-pay|Self-pay|261||||261|52.2|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|TML [1980]|TML [198000]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261||||261|10.12|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261||||261|16.57|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNICARE [2040]|UNICARE [204000]|261||||261|16.57|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261||||261|16.57|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|261||||261|180.09|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261||||261|12.05|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261||||261|24.1|180.09|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|261||||261|16.57|180.09|10.12
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AARP [1000]|AARP [100000]|468.75||||468.75|16.18|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA [1015]|AETNA [101529]|468.75||||468.75|210.94|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMBETTER [2930]|AMBETTER [293000]|468.75||||468.75|12.36|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|468.75||||468.75|234.38|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|468.75||||468.75|187.5|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|468.75||||468.75|187.5|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|468.75||||468.75|220.31|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|468.75||||468.75|192.19|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA [1260]|CIGNA PPO [126025]|468.75||||468.75|34.52|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|468.75||||468.75|16.18|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|468.75||||468.75|234.38|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|468.75||||468.75|210.94|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|468.75||||468.75|210.94|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|468.75||||468.75|0|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|Self-pay|Self-pay|468.75||||468.75|93.75|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|TML [1980]|TML [198000]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|468.75||||468.75|9.89|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|468.75||||468.75|16.18|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNICARE [2040]|UNICARE [204000]|468.75||||468.75|16.18|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|468.75||||468.75|16.18|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WEB TPA [2115]|WEB TPA [211500]|468.75||||468.75|323.44|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|468.75||||468.75|11.77|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|468.75||||468.75|23.54|323.44|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WORKER'S COMP [2125]|TML WC [212537]|468.75||||468.75|16.18|323.44|9.89
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AARP [1000]|AARP [100000]|428||||428|14.76|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA [1015]|AETNA [101529]|428||||428|192.6|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMBETTER [2930]|AMBETTER [293000]|428||||428|11.28|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|428||||428|214|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|428||||428|171.2|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|428||||428|171.2|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|428||||428|201.16|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|428||||428|175.48|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA [1260]|CIGNA PPO [126025]|428||||428|31.48|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|428||||428|14.76|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|428||||428|214|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|428||||428|192.6|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|428||||428|192.6|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|428||||428|0|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|Self-pay|Self-pay|428||||428|85.6|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|TML [1980]|TML [198000]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|428||||428|9.02|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|428||||428|14.76|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNICARE [2040]|UNICARE [204000]|428||||428|14.76|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|428||||428|14.76|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WEB TPA [2115]|WEB TPA [211500]|428||||428|295.32|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|428||||428|10.74|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|428||||428|21.48|295.32|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WORKER'S COMP [2125]|TML WC [212537]|428||||428|14.76|295.32|9.02
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AARP [1000]|AARP [100000]|244||||244|15.47|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AETNA [1015]|AETNA [101529]|244||||244|109.8|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AMBETTER [2930]|AMBETTER [293000]|244||||244|11.82|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244||||244|122|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|97.6|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|97.6|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|114.68|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244||||244|100.04|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA [1260]|CIGNA PPO [126025]|244||||244|32.97|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244||||244|15.47|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244||||244|122|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|109.8|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|109.8|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244|0|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|Self-pay|Self-pay|244||||244|48.8|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|TML [1980]|TML [198000]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244|9.46|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244|15.47|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UNICARE [2040]|UNICARE [204000]|244||||244|15.47|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244|15.47|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WEB TPA [2115]|WEB TPA [211500]|244||||244|168.36|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244|11.26|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244|22.52|168.36|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WORKER'S COMP [2125]|TML WC [212537]|244||||244|15.47|168.36|9.46
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AARP [1000]|AARP [100000]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|297|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|330|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|264|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|264|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|310.2|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|270.6|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|44.85|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|330|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|297|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|297|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99|0|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|Self-pay|Self-pay|659.99||||659.99|132|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99||455.39|44.85
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||455.39|44.85
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AARP [1000]|AARP [100000]|527.75||||527.75|18.2|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA [1015]|AETNA [101529]|527.75||||527.75|237.49|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMBETTER [2930]|AMBETTER [293000]|527.75||||527.75|13.9|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|527.75||||527.75|263.88|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|527.75||||527.75|211.1|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|527.75||||527.75|211.1|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|527.75||||527.75|248.04|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|527.75||||527.75|216.38|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA [1260]|CIGNA PPO [126025]|527.75||||527.75|38.83|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|527.75||||527.75|18.2|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|527.75||||527.75|263.88|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|527.75||||527.75|237.49|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|527.75||||527.75|237.49|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|527.75||||527.75|0|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|Self-pay|Self-pay|527.75||||527.75|105.55|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|TML [1980]|TML [198000]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|527.75||||527.75|11.12|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|527.75||||527.75|18.2|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNICARE [2040]|UNICARE [204000]|527.75||||527.75|18.2|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|527.75||||527.75|18.2|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WEB TPA [2115]|WEB TPA [211500]|527.75||||527.75|364.15|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|527.75||||527.75|13.24|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|527.75||||527.75|26.48|364.15|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WORKER'S COMP [2125]|TML WC [212537]|527.75||||527.75|18.2|364.15|11.12
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AARP [1000]|AARP [100000]|309||||309|19.62|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AETNA [1015]|AETNA [101529]|309||||309|139.05|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AMBETTER [2930]|AMBETTER [293000]|309||||309|14.98|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|309||||309|154.5|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|309||||309|123.6|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|309||||309|123.6|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|309||||309|145.23|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|309||||309|126.69|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA [1260]|CIGNA PPO [126025]|309||||309|41.84|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|309||||309|19.62|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|309||||309|154.5|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|309||||309|139.05|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|309||||309|139.05|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|309||||309|0|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|Self-pay|Self-pay|309||||309|61.8|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|TML [1980]|TML [198000]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|309||||309|11.99|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|309||||309|19.62|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UNICARE [2040]|UNICARE [204000]|309||||309|19.62|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|309||||309|19.62|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WEB TPA [2115]|WEB TPA [211500]|309||||309|213.21|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|309||||309|14.27|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|309||||309|28.54|213.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WORKER'S COMP [2125]|TML WC [212537]|309||||309|19.62|213.21|11.99
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AARP [1000]|AARP [100000]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA [1015]|AETNA [101529]|351.36||||351.36|158.11|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMBETTER [2930]|AMBETTER [293000]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|351.36||||351.36|175.68|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351.36||||351.36|140.54|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351.36||||351.36|140.54|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351.36||||351.36|165.14|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|351.36||||351.36|144.06|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA [1260]|CIGNA PPO [126025]|351.36||||351.36|15.76|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|351.36||||351.36|175.68|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351.36||||351.36|158.11|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351.36||||351.36|158.11|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351.36||||351.36|0|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|Self-pay|Self-pay|351.36||||351.36|70.27|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|TML [1980]|TML [198000]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNICARE [2040]|UNICARE [204000]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WEB TPA [2115]|WEB TPA [211500]|351.36||||351.36|242.44|242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351.36||||351.36||242.44|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WORKER'S COMP [2125]|TML WC [212537]|351.36||||351.36||242.44|15.76
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AARP [1000]|AARP [100000]|227.75||||227.75|7.87|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA [1015]|AETNA [101529]|227.75||||227.75|102.49|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMBETTER [2930]|AMBETTER [293000]|227.75||||227.75|150.65|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|227.75||||227.75|113.88|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|227.75||||227.75|91.1|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|227.75||||227.75|91.1|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|227.75||||227.75|107.04|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|227.75||||227.75|93.38|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA [1260]|CIGNA PPO [126025]|227.75||||227.75|16.78|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|227.75||||227.75|7.87|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|227.75||||227.75|113.88|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|227.75||||227.75|102.49|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|227.75||||227.75|102.49|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|227.75||||227.75|0|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|Self-pay|Self-pay|227.75||||227.75|45.55|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|TML [1980]|TML [198000]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|227.75||||227.75|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|227.75||||227.75|7.87|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNICARE [2040]|UNICARE [204000]|227.75||||227.75|7.87|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|227.75||||227.75|7.87|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WEB TPA [2115]|WEB TPA [211500]|227.75||||227.75|157.15|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|227.75||||227.75|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|227.75||||227.75|270.52|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WORKER'S COMP [2125]|TML WC [212537]|227.75||||227.75|7.87|270.52|4.8
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AARP [1000]|AARP [100000]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA [1015]|AETNA [101529]|351.36||||351.36|158.11|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMBETTER [2930]|AMBETTER [293000]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|351.36||||351.36|175.68|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351.36||||351.36|140.54|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351.36||||351.36|140.54|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351.36||||351.36|165.14|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|351.36||||351.36|144.06|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA [1260]|CIGNA PPO [126025]|351.36||||351.36|15.16|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|351.36||||351.36|175.68|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351.36||||351.36|158.11|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351.36||||351.36|158.11|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351.36||||351.36|0|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|Self-pay|Self-pay|351.36||||351.36|70.27|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|TML [1980]|TML [198000]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNICARE [2040]|UNICARE [204000]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WEB TPA [2115]|WEB TPA [211500]|351.36||||351.36|242.44|242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351.36||||351.36||242.44|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WORKER'S COMP [2125]|TML WC [212537]|351.36||||351.36||242.44|15.16
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AARP [1000]|AARP [100000]|182.88||||182.88|4.1|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA [1015]|AETNA [101529]|182.88||||182.88|82.3|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMBETTER [2930]|AMBETTER [293000]|182.88||||182.88|113.07|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|182.88||||182.88|91.44|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.88||||182.88|73.15|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.88||||182.88|73.15|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.88||||182.88|85.95|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|182.88||||182.88|74.98|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA [1260]|CIGNA PPO [126025]|182.88||||182.88|8.77|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|182.88||||182.88|4.1|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|182.88||||182.88|91.44|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.88||||182.88|82.3|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.88||||182.88|82.3|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.88||||182.88|0|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|Self-pay|Self-pay|182.88||||182.88|36.58|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|TML [1980]|TML [198000]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.88||||182.88|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.88||||182.88|4.1|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNICARE [2040]|UNICARE [204000]|182.88||||182.88|4.1|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.88||||182.88|4.1|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WEB TPA [2115]|WEB TPA [211500]|182.88||||182.88|126.19|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.88||||182.88|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.88||||182.88|203.04|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WORKER'S COMP [2125]|TML WC [212537]|182.88||||182.88|4.1|203.04|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AARP [1000]|AARP [100000]|182.88||||182.88|4.1|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA [1015]|AETNA [101529]|182.88||||182.88|82.3|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMBETTER [2930]|AMBETTER [293000]|182.88||||182.88|34.18|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|182.88||||182.88|91.44|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.88||||182.88|73.15|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.88||||182.88|73.15|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.88||||182.88|85.95|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|182.88||||182.88|74.98|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA [1260]|CIGNA PPO [126025]|182.88||||182.88|8.77|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|182.88||||182.88|4.1|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|182.88||||182.88|91.44|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.88||||182.88|82.3|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.88||||182.88|82.3|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.88||||182.88|0|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|Self-pay|Self-pay|182.88||||182.88|36.58|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|TML [1980]|TML [198000]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.88||||182.88|2.51|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.88||||182.88|4.1|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNICARE [2040]|UNICARE [204000]|182.88||||182.88|4.1|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.88||||182.88|4.1|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WEB TPA [2115]|WEB TPA [211500]|182.88||||182.88|126.19|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.88||||182.88|30.69|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.88||||182.88|61.37|126.19|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WORKER'S COMP [2125]|TML WC [212537]|182.88||||182.88|4.1|126.19|2.51
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AARP [1000]|AARP [100000]|580.32||||580.32|5.25|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AETNA [1015]|AETNA [101529]|580.32||||580.32|261.14|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AMBETTER [2930]|AMBETTER [293000]|580.32||||580.32|277.32|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.32||||580.32|290.16|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580.32||||580.32|232.13|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580.32||||580.32|232.13|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580.32||||580.32|272.75|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.32||||580.32|237.93|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA [1260]|CIGNA PPO [126025]|580.32||||580.32|11.22|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.32||||580.32|5.25|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.32||||580.32|290.16|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.32||||580.32|261.14|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.32||||580.32|261.14|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.32||||580.32|0|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|Self-pay|Self-pay|580.32||||580.32|116.06|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|TML [1980]|TML [198000]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580.32||||580.32|5.33|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.32||||580.32|5.25|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UNICARE [2040]|UNICARE [204000]|580.32||||580.32|5.25|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.32||||580.32|5.25|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WEB TPA [2115]|WEB TPA [211500]|580.32||||580.32|400.42|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.32||||580.32|264.12|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580.32||||580.32|528.23|528.23|5.25
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WORKER'S COMP [2125]|TML WC [212537]|580.32||||580.32|5.25|528.23|5.25
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AARP [1000]|AARP [100000]|609.12||||609.12|17.96|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA [1015]|AETNA [101529]|609.12||||609.12|274.1|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMBETTER [2930]|AMBETTER [293000]|609.12||||609.12|162.6|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.12||||609.12|304.56|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.12||||609.12|243.65|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.12||||609.12|243.65|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.12||||609.12|286.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|609.12||||609.12|249.74|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|609.12||||609.12|73.18|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.12||||609.12|17.96|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.12||||609.12|304.56|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.12||||609.12|274.1|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.12||||609.12|274.1|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.12||||609.12|0|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|Self-pay|Self-pay|609.12||||609.12|121.82|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|TML [1980]|TML [198000]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.12||||609.12|85.28|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.12||||609.12|17.96|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNICARE [2040]|UNICARE [204000]|609.12||||609.12|17.96|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.12||||609.12|17.96|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WEB TPA [2115]|WEB TPA [211500]|609.12||||609.12|420.29|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.12||||609.12|154.86|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.12||||609.12|309.72|420.29|17.96
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AARP [1000]|AARP [100000]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA [1015]|AETNA [101529]|609.12||||609.12|274.1|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMBETTER [2930]|AMBETTER [293000]|609.12||||609.12|142.02|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.12||||609.12|304.56|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.12||||609.12|243.65|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.12||||609.12|243.65|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.12||||609.12|286.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|609.12||||609.12|249.74|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA [1260]|CIGNA PPO [126025]|609.12||||609.12|58.55|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.12||||609.12|304.56|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.12||||609.12|274.1|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.12||||609.12|274.1|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.12||||609.12|0|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|Self-pay|Self-pay|609.12||||609.12|121.82|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|TML [1980]|TML [198000]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.12||||609.12|85.28|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNICARE [2040]|UNICARE [204000]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.12||||609.12|17.96|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WEB TPA [2115]|WEB TPA [211500]|609.12||||609.12|420.29|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.12||||609.12|135.26|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.12||||609.12|270.52|420.29|17.96
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WORKER'S COMP [2125]|TML WC [212537]|609.12||||609.12|17.96|420.29|17.96
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AARP [1000]|AARP [100000]|216.66||||216.66|4.73|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA [1015]|AETNA [101529]|216.66||||216.66|97.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMBETTER [2930]|AMBETTER [293000]|216.66||||216.66|3.99|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.66||||216.66|108.33|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.66||||216.66|86.66|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.66||||216.66|86.66|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.66||||216.66|101.83|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.66||||216.66|88.83|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA [1260]|CIGNA PPO [126025]|216.66||||216.66|10.06|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.66||||216.66|4.73|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.66||||216.66|108.33|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.66||||216.66|97.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.66||||216.66|97.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.66||||216.66|0|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|Self-pay|Self-pay|216.66||||216.66|43.33|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|TML [1980]|TML [198000]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.66||||216.66|3.19|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.66||||216.66|4.73|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNICARE [2040]|UNICARE [204000]|216.66||||216.66|4.73|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.66||||216.66|4.73|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WEB TPA [2115]|WEB TPA [211500]|216.66||||216.66|149.5|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.66||||216.66|3.8|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216.66||||216.66|7.6|149.5|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WORKER'S COMP [2125]|TML WC [212537]|216.66||||216.66|4.73|149.5|3.19
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AARP [1000]|AARP [100000]|149.04||||149.04|3.26|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA [1015]|AETNA [101529]|149.04||||149.04|67.07|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMBETTER [2930]|AMBETTER [293000]|149.04||||149.04|2.49|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.04||||149.04|74.52|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.04||||149.04|59.62|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.04||||149.04|59.62|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.04||||149.04|70.05|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.04||||149.04|61.11|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA [1260]|CIGNA PPO [126025]|149.04||||149.04|6.95|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.04||||149.04|3.26|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.04||||149.04|74.52|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.04||||149.04|67.07|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.04||||149.04|67.07|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.04||||149.04|0|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|Self-pay|Self-pay|149.04||||149.04|29.81|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|TML [1980]|TML [198000]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.04||||149.04|1.99|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.04||||149.04|3.26|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNICARE [2040]|UNICARE [204000]|149.04||||149.04|3.26|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.04||||149.04|3.26|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WEB TPA [2115]|WEB TPA [211500]|149.04||||149.04|102.84|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.04||||149.04|2.37|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.04||||149.04|4.74|102.84|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WORKER'S COMP [2125]|TML WC [212537]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AARP [1000]|AARP [100000]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA [1015]|AETNA [101529]|149.04||||149.04|67.07|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMBETTER [2930]|AMBETTER [293000]|149.04||||149.04|2.49|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.04||||149.04|74.52|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.04||||149.04|59.62|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.04||||149.04|59.62|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.04||||149.04|70.05|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.04||||149.04|61.11|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA [1260]|CIGNA PPO [126025]|149.04||||149.04|6.95|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.04||||149.04|74.52|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.04||||149.04|67.07|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.04||||149.04|67.07|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.04||||149.04|0|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|Self-pay|Self-pay|149.04||||149.04|29.81|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|TML [1980]|TML [198000]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.04||||149.04|1.99|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNICARE [2040]|UNICARE [204000]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.04||||149.04|3.26|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WEB TPA [2115]|WEB TPA [211500]|149.04||||149.04|102.84|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.04||||149.04|2.37|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.04||||149.04|4.74|102.84|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WORKER'S COMP [2125]|TML WC [212537]|149.04||||149.04|3.26|102.84|1.99
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AARP [1000]|AARP [100000]|222.18||||222.18|10.69|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA [1015]|AETNA [101529]|222.18||||222.18|99.98|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMBETTER [2930]|AMBETTER [293000]|222.18||||222.18|8.16|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|222.18||||222.18|111.09|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|222.18||||222.18|88.87|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|222.18||||222.18|88.87|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|222.18||||222.18|104.42|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|222.18||||222.18|91.09|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|222.18||||222.18|22.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|222.18||||222.18|10.69|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|222.18||||222.18|111.09|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|222.18||||222.18|99.98|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|222.18||||222.18|99.98|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|222.18||||222.18|0|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|Self-pay|Self-pay|222.18||||222.18|44.44|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|TML [1980]|TML [198000]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|222.18||||222.18|6.53|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|222.18||||222.18|10.69|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNICARE [2040]|UNICARE [204000]|222.18||||222.18|10.69|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|222.18||||222.18|10.69|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WEB TPA [2115]|WEB TPA [211500]|222.18||||222.18|153.3|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|222.18||||222.18|7.77|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|222.18||||222.18|15.54|153.3|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|222.18||||222.18|10.69|153.3|6.53
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AARP [1000]|AARP [100000]|408.48||||408.48|8.89|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA [1015]|AETNA [101529]|408.48||||408.48|183.82|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMBETTER [2930]|AMBETTER [293000]|408.48||||408.48|6.79|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408.48||||408.48|204.24|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.48||||408.48|163.39|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.48||||408.48|163.39|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.48||||408.48|191.99|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408.48||||408.48|167.48|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|408.48||||408.48|18.97|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408.48||||408.48|8.89|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408.48||||408.48|204.24|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.48||||408.48|183.82|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.48||||408.48|183.82|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.48||||408.48|0|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|Self-pay|Self-pay|408.48||||408.48|81.7|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|TML [1980]|TML [198000]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.48||||408.48|5.43|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.48||||408.48|8.89|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNICARE [2040]|UNICARE [204000]|408.48||||408.48|8.89|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.48||||408.48|8.89|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WEB TPA [2115]|WEB TPA [211500]|408.48||||408.48|281.85|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.48||||408.48|6.47|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.48||||408.48|12.94|281.85|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|408.48||||408.48|8.89|281.85|5.43
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AARP [1000]|AARP [100000]|270.48||||270.48|5.5|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA [1015]|AETNA [101529]|270.48||||270.48|121.72|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMBETTER [2930]|AMBETTER [293000]|270.48||||270.48|4.19|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|270.48||||270.48|135.24|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270.48||||270.48|108.19|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270.48||||270.48|108.19|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270.48||||270.48|127.13|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|270.48||||270.48|110.9|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|270.48||||270.48|11.72|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|270.48||||270.48|5.5|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|270.48||||270.48|135.24|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270.48||||270.48|121.72|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270.48||||270.48|121.72|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270.48||||270.48|0|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|Self-pay|Self-pay|270.48||||270.48|54.1|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|TML [1980]|TML [198000]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270.48||||270.48|3.35|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270.48||||270.48|5.5|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNICARE [2040]|UNICARE [204000]|270.48||||270.48|5.5|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270.48||||270.48|5.5|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WEB TPA [2115]|WEB TPA [211500]|270.48||||270.48|186.63|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270.48||||270.48|3.99|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270.48||||270.48|7.98|186.63|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|270.48||||270.48|5.5|186.63|3.35
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AARP [1000]|AARP [100000]|132.48||||132.48|6.15|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AETNA [1015]|AETNA [101529]|132.48||||132.48|59.62|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AMBETTER [2930]|AMBETTER [293000]|132.48||||132.48|4.7|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132.48||||132.48|66.24|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132.48||||132.48|52.99|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132.48||||132.48|52.99|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132.48||||132.48|62.27|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132.48||||132.48|54.32|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|132.48||||132.48|13.14|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132.48||||132.48|6.15|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132.48||||132.48|66.24|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.48||||132.48|59.62|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.48||||132.48|59.62|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.48||||132.48|0|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|Self-pay|Self-pay|132.48||||132.48|26.5|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|TML [1980]|TML [198000]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132.48||||132.48|3.76|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.48||||132.48|6.15|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UNICARE [2040]|UNICARE [204000]|132.48||||132.48|6.15|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.48||||132.48|6.15|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WEB TPA [2115]|WEB TPA [211500]|132.48||||132.48|91.41|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.48||||132.48|4.48|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132.48||||132.48|8.96|91.41|3.76
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|132.48||||132.48|6.15|91.41|3.76
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AARP [1000]|AARP [100000]|2109.6||||2109.6|38.1|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA [1015]|AETNA [101529]|2109.6||||2109.6|949.32|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMBETTER [2930]|AMBETTER [293000]|2109.6||||2109.6|624.76|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2109.6||||2109.6|1054.8|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2109.6||||2109.6|843.84|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2109.6||||2109.6|843.84|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2109.6||||2109.6|991.51|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2109.6||||2109.6|864.94|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA [1260]|CIGNA PPO [126025]|2109.6||||2109.6|109.4|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2109.6||||2109.6|38.1|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2109.6||||2109.6|1054.8|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2109.6||||2109.6|949.32|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2109.6||||2109.6|949.32|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2109.6||||2109.6|0|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|Self-pay|Self-pay|2109.6||||2109.6|421.92|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|TML [1980]|TML [198000]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2109.6||||2109.6|295.34|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2109.6||||2109.6|38.1|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNICARE [2040]|UNICARE [204000]|2109.6||||2109.6|38.1|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2109.6||||2109.6|38.1|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WEB TPA [2115]|WEB TPA [211500]|2109.6||||2109.6|1455.62|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2109.6||||2109.6|595.01|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2109.6||||2109.6|1190.02|1455.62|38.1
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WORKER'S COMP [2125]|TML WC [212537]|2109.6||||2109.6|38.1|1455.62|38.1
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AARP [1000]|AARP [100000]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA [1015]|AETNA [101529]|817.72||||817.72|367.97|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMBETTER [2930]|AMBETTER [293000]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|817.72||||817.72|408.86|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|817.72||||817.72|327.09|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|817.72||||817.72|327.09|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|817.72||||817.72|384.33|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|817.72||||817.72|335.27|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA [1260]|CIGNA PPO [126025]|817.72||||817.72|38.07|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|817.72||||817.72|408.86|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|817.72||||817.72|367.97|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|817.72||||817.72|367.97|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|817.72||||817.72|0|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|Self-pay|Self-pay|817.72||||817.72|163.54|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|TML [1980]|TML [198000]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNICARE [2040]|UNICARE [204000]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WEB TPA [2115]|WEB TPA [211500]|817.72||||817.72|564.23|564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|817.72||||817.72||564.23|38.07
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WORKER'S COMP [2125]|TML WC [212537]|817.72||||817.72||564.23|38.07
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AARP [1000]|AARP [100000]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA [1015]|AETNA [101529]|1113.66||||1113.66|501.15|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMBETTER [2930]|AMBETTER [293000]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1113.66||||1113.66|556.83|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1113.66||||1113.66|445.46|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1113.66||||1113.66|445.46|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1113.66||||1113.66|523.42|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1113.66||||1113.66|456.6|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA [1260]|CIGNA PPO [126025]|1113.66||||1113.66|51.74|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1113.66||||1113.66|556.83|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1113.66||||1113.66|501.15|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1113.66||||1113.66|501.15|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1113.66||||1113.66|0|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|Self-pay|Self-pay|1113.66||||1113.66|222.73|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|TML [1980]|TML [198000]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNICARE [2040]|UNICARE [204000]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WEB TPA [2115]|WEB TPA [211500]|1113.66||||1113.66|768.43|768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1113.66||||1113.66||768.43|51.74
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WORKER'S COMP [2125]|TML WC [212537]|1113.66||||1113.66||768.43|51.74
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|508.6|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|565.11|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|452.09|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|452.09|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|531.2|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|463.39|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|565.11|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|508.6|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|508.6|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22|0|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22||779.85|52.46
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||779.85|52.46
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AARP [1000]|AARP [100000]|478.86||||478.86|24.61|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA [1015]|AETNA [101529]|478.86||||478.86|215.49|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMBETTER [2930]|AMBETTER [293000]|478.86||||478.86|18.8|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.86||||478.86|239.43|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.86||||478.86|191.54|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.86||||478.86|191.54|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.86||||478.86|225.06|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.86||||478.86|196.33|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA [1260]|CIGNA PPO [126025]|478.86||||478.86|52.46|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.86||||478.86|24.61|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.86||||478.86|239.43|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.86||||478.86|215.49|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.86||||478.86|215.49|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.86||||478.86|0|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|Self-pay|Self-pay|478.86||||478.86|95.77|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|TML [1980]|TML [198000]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.86||||478.86|15.04|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.86||||478.86|24.61|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNICARE [2040]|UNICARE [204000]|478.86||||478.86|24.61|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.86||||478.86|24.61|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WEB TPA [2115]|WEB TPA [211500]|478.86||||478.86|330.41|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.86||||478.86|17.9|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.86||||478.86|35.8|330.41|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WORKER'S COMP [2125]|TML WC [212537]|478.86||||478.86|24.61|330.41|15.04
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|508.6|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|565.11|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|452.09|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|452.09|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|531.2|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|463.39|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|565.11|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|508.6|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|508.6|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22|0|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22||779.85|52.46
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|508.6|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|565.11|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|452.09|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|452.09|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|531.2|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|463.39|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|565.11|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|508.6|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|508.6|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22|0|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22||779.85|52.46
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||779.85|52.46
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AARP [1000]|AARP [100000]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AETNA [1015]|AETNA [101529]|747.96||||747.96|336.58|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|747.96||||747.96|373.98|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747.96||||747.96|299.18|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747.96||||747.96|299.18|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747.96||||747.96|351.54|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|747.96||||747.96|306.66|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|747.96||||747.96|34.76|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|747.96||||747.96|373.98|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747.96||||747.96|336.58|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747.96||||747.96|336.58|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747.96||||747.96|0|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|Self-pay|Self-pay|747.96||||747.96|149.59|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|TML [1980]|TML [198000]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|747.96||||747.96|516.09|516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747.96||||747.96||516.09|34.76
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|747.96||||747.96||516.09|34.76
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AARP [1000]|AARP [100000]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA [1015]|AETNA [101529]|594.43||||594.43|267.49|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.43||||594.43|297.22|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.43||||594.43|237.77|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.43||||594.43|237.77|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.43||||594.43|279.38|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.43||||594.43|243.72|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|594.43||||594.43|31.68|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.43||||594.43|297.22|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.43||||594.43|267.49|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.43||||594.43|267.49|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.43||||594.43|0|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|Self-pay|Self-pay|594.43||||594.43|118.89|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|TML [1980]|TML [198000]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNICARE [2040]|UNICARE [204000]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|594.43||||594.43|410.16|410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.43||||594.43||410.16|31.68
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|594.43||||594.43||410.16|31.68
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AARP [1000]|AARP [100000]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA [1015]|AETNA [101529]|760.03||||760.03|342.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|760.03||||760.03|380.02|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|760.03||||760.03|304.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|760.03||||760.03|304.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|760.03||||760.03|357.21|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|760.03||||760.03|311.61|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|760.03||||760.03|40.55|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|760.03||||760.03|380.02|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|760.03||||760.03|342.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|760.03||||760.03|342.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|760.03||||760.03|0|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|Self-pay|Self-pay|760.03||||760.03|152.01|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|TML [1980]|TML [198000]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|760.03||||760.03|524.42|524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|760.03||||760.03||524.42|40.55
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|760.03||||760.03||524.42|40.55
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AARP [1000]|AARP [100000]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AETNA [1015]|AETNA [101529]|758.65||||758.65|341.39|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|758.65||||758.65|379.33|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|758.65||||758.65|303.46|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|758.65||||758.65|303.46|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|758.65||||758.65|356.57|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|758.65||||758.65|311.05|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|758.65||||758.65|44.92|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|758.65||||758.65|379.33|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|758.65||||758.65|341.39|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|758.65||||758.65|341.39|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|758.65||||758.65|0|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|Self-pay|Self-pay|758.65||||758.65|151.73|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|TML [1980]|TML [198000]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UNICARE [2040]|UNICARE [204000]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|758.65||||758.65|523.47|523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|758.65||||758.65||523.47|44.92
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|758.65||||758.65||523.47|44.92
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AARP [1000]|AARP [100000]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA [1015]|AETNA [101529]|812.82||||812.82|365.77|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMBETTER [2930]|AMBETTER [293000]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|812.82||||812.82|406.41|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|812.82||||812.82|325.13|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|812.82||||812.82|325.13|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|812.82||||812.82|382.03|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|812.82||||812.82|333.26|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA [1260]|CIGNA PPO [126025]|812.82||||812.82|37.7|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|812.82||||812.82|406.41|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|812.82||||812.82|365.77|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|812.82||||812.82|365.77|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|812.82||||812.82|0|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|Self-pay|Self-pay|812.82||||812.82|162.56|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|TML [1980]|TML [198000]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNICARE [2040]|UNICARE [204000]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WEB TPA [2115]|WEB TPA [211500]|812.82||||812.82|560.85|560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|812.82||||812.82||560.85|37.7
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WORKER'S COMP [2125]|TML WC [212537]|812.82||||812.82||560.85|37.7
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AARP [1000]|AARP [100000]|325.68||||325.68|5.85|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AETNA [1015]|AETNA [101529]|325.68||||325.68|146.56|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMBETTER [2930]|AMBETTER [293000]|325.68||||325.68|4.49|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|325.68||||325.68|162.84|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|325.68||||325.68|130.27|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|325.68||||325.68|130.27|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|325.68||||325.68|153.07|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|325.68||||325.68|133.53|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA [1260]|CIGNA PPO [126025]|325.68||||325.68|12.48|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|325.68||||325.68|5.85|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|325.68||||325.68|162.84|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|325.68||||325.68|146.56|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|325.68||||325.68|146.56|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|325.68||||325.68|0|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|Self-pay|Self-pay|325.68||||325.68|65.14|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|TML [1980]|TML [198000]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|325.68||||325.68|3.6|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|325.68||||325.68|5.85|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UNICARE [2040]|UNICARE [204000]|325.68||||325.68|5.85|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|325.68||||325.68|5.85|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WEB TPA [2115]|WEB TPA [211500]|325.68||||325.68|224.72|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|325.68||||325.68|4.28|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|325.68||||325.68|8.56|224.72|3.6
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WORKER'S COMP [2125]|TML WC [212537]|325.68||||325.68|5.85|224.72|3.6
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AARP [1000]|AARP [100000]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA [1015]|AETNA [101529]|434.7||||434.7|195.62|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMBETTER [2930]|AMBETTER [293000]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|434.7||||434.7|217.35|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|434.7||||434.7|173.88|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|434.7||||434.7|173.88|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|434.7||||434.7|204.31|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|434.7||||434.7|178.23|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA [1260]|CIGNA PPO [126025]|434.7||||434.7|20.19|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|434.7||||434.7|217.35|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|434.7||||434.7|195.62|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|434.7||||434.7|195.62|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|434.7||||434.7|0|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|Self-pay|Self-pay|434.7||||434.7|86.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|TML [1980]|TML [198000]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNICARE [2040]|UNICARE [204000]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WEB TPA [2115]|WEB TPA [211500]|434.7||||434.7|299.94|299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|434.7||||434.7||299.94|20.19
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WORKER'S COMP [2125]|TML WC [212537]|434.7||||434.7||299.94|20.19
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AARP [1000]|AARP [100000]|449.88||||449.88|13.99|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|202.45|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|10.69|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|224.94|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|179.95|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|179.95|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|211.44|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|184.45|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|29.86|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88|13.99|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|224.94|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|202.45|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|202.45|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88|0|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|Self-pay|Self-pay|449.88||||449.88|89.98|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88|8.55|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88|13.99|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88|13.99|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88|13.99|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|10.18|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449.88||||449.88|20.36|310.42|8.55
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88|13.99|310.42|8.55
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AARP [1000]|AARP [100000]|535.44||||535.44|11.68|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA [1015]|AETNA [101529]|535.44||||535.44|240.95|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|535.44||||535.44|10.21|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|535.44||||535.44|267.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|535.44||||535.44|214.18|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|535.44||||535.44|214.18|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|535.44||||535.44|251.66|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|535.44||||535.44|219.53|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|535.44||||535.44|24.89|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|535.44||||535.44|11.68|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|535.44||||535.44|267.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|535.44||||535.44|240.95|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|535.44||||535.44|240.95|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|535.44||||535.44|0|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|Self-pay|Self-pay|535.44||||535.44|107.09|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|TML [1980]|TML [198000]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|535.44||||535.44|8.16|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|535.44||||535.44|11.68|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|535.44||||535.44|11.68|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|535.44||||535.44|11.68|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|535.44||||535.44|369.45|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|535.44||||535.44|9.72|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|535.44||||535.44|19.44|369.45|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|535.44||||535.44|11.68|369.45|8.16
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AARP [1000]|AARP [100000]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA [1015]|AETNA [101529]|314||||314|141.3|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMBETTER [2930]|AMBETTER [293000]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|314||||314|157|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|314||||314|125.6|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|314||||314|125.6|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|314||||314|147.58|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|314||||314|128.74|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA [1260]|CIGNA PPO [126025]|314||||314|67.23|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|314||||314|157|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|314||||314|141.3|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|314||||314|141.3|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|314||||314|0|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|Self-pay|Self-pay|314||||314|62.8|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|TML [1980]|TML [198000]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNICARE [2040]|UNICARE [204000]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WEB TPA [2115]|WEB TPA [211500]|314||||314|216.66|216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|314||||314||216.66|62.8
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WORKER'S COMP [2125]|TML WC [212537]|314||||314||216.66|62.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AARP [1000]|AARP [100000]|825.24||||825.24|18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA [1015]|AETNA [101529]|825.24||||825.24|371.36|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|825.24||||825.24|13.74|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|825.24||||825.24|412.62|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|825.24||||825.24|330.1|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|825.24||||825.24|330.1|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|825.24||||825.24|387.86|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|825.24||||825.24|338.35|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|825.24||||825.24|38.36|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|825.24||||825.24|18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|825.24||||825.24|412.62|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|825.24||||825.24|371.36|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|825.24||||825.24|371.36|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|825.24||||825.24|0|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|Self-pay|Self-pay|825.24||||825.24|165.05|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|TML [1980]|TML [198000]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|825.24||||825.24|11|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|825.24||||825.24|18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNICARE [2040]|UNICARE [204000]|825.24||||825.24|18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|825.24||||825.24|18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|825.24||||825.24|569.42|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|825.24||||825.24|13.09|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|825.24||||825.24|26.18|569.42|11
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|825.24||||825.24|18|569.42|11
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AARP [1000]|AARP [100000]|1355.16||||1355.16|29.53|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA [1015]|AETNA [101529]|1355.16||||1355.16|609.82|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMBETTER [2930]|AMBETTER [293000]|1355.16||||1355.16|26.16|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1355.16||||1355.16|677.58|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1355.16||||1355.16|542.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1355.16||||1355.16|542.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1355.16||||1355.16|636.93|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1355.16||||1355.16|555.62|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA [1260]|CIGNA PPO [126025]|1355.16||||1355.16|62.99|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1355.16||||1355.16|29.53|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1355.16||||1355.16|677.58|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1355.16||||1355.16|609.82|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1355.16||||1355.16|609.82|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1355.16||||1355.16|0|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|Self-pay|Self-pay|1355.16||||1355.16|271.03|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|TML [1980]|TML [198000]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1355.16||||1355.16|20.92|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1355.16||||1355.16|29.53|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNICARE [2040]|UNICARE [204000]|1355.16||||1355.16|29.53|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1355.16||||1355.16|29.53|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WEB TPA [2115]|WEB TPA [211500]|1355.16||||1355.16|935.06|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1355.16||||1355.16|24.91|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1355.16||||1355.16|49.82|935.06|20.92
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WORKER'S COMP [2125]|TML WC [212537]|1355.16||||1355.16|29.53|935.06|20.92
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AARP [1000]|AARP [100000]|156.5||||156.5|5.4|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA [1015]|AETNA [101529]|156.5||||156.5|70.43|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMBETTER [2930]|AMBETTER [293000]|156.5||||156.5|4.5|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|156.5||||156.5|78.25|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156.5||||156.5|62.6|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156.5||||156.5|62.6|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156.5||||156.5|73.56|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|156.5||||156.5|64.17|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA [1260]|CIGNA PPO [126025]|156.5||||156.5|11.52|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|156.5||||156.5|5.4|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|156.5||||156.5|78.25|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156.5||||156.5|70.43|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156.5||||156.5|70.43|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156.5||||156.5|0|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|Self-pay|Self-pay|156.5||||156.5|31.3|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|TML [1980]|TML [198000]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156.5||||156.5|3.6|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156.5||||156.5|5.4|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNICARE [2040]|UNICARE [204000]|156.5||||156.5|5.4|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156.5||||156.5|5.4|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WEB TPA [2115]|WEB TPA [211500]|156.5||||156.5|107.99|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156.5||||156.5|4.29|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156.5||||156.5|8.58|107.99|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WORKER'S COMP [2125]|TML WC [212537]|156.5||||156.5|5.4|107.99|3.6
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AARP [1000]|AARP [100000]|441.6||||441.6|13.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA [1015]|AETNA [101529]|441.6||||441.6|198.72|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMBETTER [2930]|AMBETTER [293000]|441.6||||441.6|10.06|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|441.6||||441.6|220.8|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|441.6||||441.6|176.64|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|441.6||||441.6|176.64|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|441.6||||441.6|207.55|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|441.6||||441.6|181.06|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA [1260]|CIGNA PPO [126025]|441.6||||441.6|28.07|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|441.6||||441.6|13.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|441.6||||441.6|220.8|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|441.6||||441.6|198.72|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|441.6||||441.6|198.72|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|441.6||||441.6|0|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|Self-pay|Self-pay|441.6||||441.6|88.32|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|TML [1980]|TML [198000]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|441.6||||441.6|8.05|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|441.6||||441.6|13.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNICARE [2040]|UNICARE [204000]|441.6||||441.6|13.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|441.6||||441.6|13.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WEB TPA [2115]|WEB TPA [211500]|441.6||||441.6|304.7|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|441.6||||441.6|9.58|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|441.6||||441.6|19.16|304.7|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WORKER'S COMP [2125]|TML WC [212537]|441.6||||441.6|13.16|304.7|8.05
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AARP [1000]|AARP [100000]|223.56||||223.56|3.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA [1015]|AETNA [101529]|223.56||||223.56|100.6|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMBETTER [2930]|AMBETTER [293000]|223.56||||223.56|2.84|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|223.56||||223.56|111.78|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223.56||||223.56|89.42|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223.56||||223.56|89.42|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223.56||||223.56|105.07|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|223.56||||223.56|91.66|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|223.56||||223.56|7.91|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|223.56||||223.56|3.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|223.56||||223.56|111.78|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223.56||||223.56|100.6|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223.56||||223.56|100.6|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223.56||||223.56|0|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|Self-pay|Self-pay|223.56||||223.56|44.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|TML [1980]|TML [198000]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223.56||||223.56|2.27|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223.56||||223.56|3.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNICARE [2040]|UNICARE [204000]|223.56||||223.56|3.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223.56||||223.56|3.71|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WEB TPA [2115]|WEB TPA [211500]|223.56||||223.56|154.26|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223.56||||223.56|2.7|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223.56||||223.56|5.4|154.26|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|223.56||||223.56|3.71|154.26|2.27
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AARP [1000]|AARP [100000]|239.25||||239.25|8.25|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA [1015]|AETNA [101529]|239.25||||239.25|107.66|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMBETTER [2930]|AMBETTER [293000]|239.25||||239.25|6.31|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|239.25||||239.25|119.63|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239.25||||239.25|95.7|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239.25||||239.25|95.7|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239.25||||239.25|112.45|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|239.25||||239.25|98.09|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA [1260]|CIGNA PPO [126025]|239.25||||239.25|17.61|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|239.25||||239.25|8.25|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|239.25||||239.25|119.63|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239.25||||239.25|107.66|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239.25||||239.25|107.66|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239.25||||239.25|0|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|Self-pay|Self-pay|239.25||||239.25|47.85|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|TML [1980]|TML [198000]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239.25||||239.25|5.05|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239.25||||239.25|8.25|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNICARE [2040]|UNICARE [204000]|239.25||||239.25|8.25|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239.25||||239.25|8.25|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WEB TPA [2115]|WEB TPA [211500]|239.25||||239.25|165.08|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239.25||||239.25|6.01|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239.25||||239.25|12.02|165.08|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WORKER'S COMP [2125]|TML WC [212537]|239.25||||239.25|8.25|165.08|5.05
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AARP [1000]|AARP [100000]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AETNA [1015]|AETNA [101529]|154||||154|69.3|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMBETTER [2930]|AMBETTER [293000]|154||||154|53.88|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|154||||154|77|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154||||154|61.6|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154||||154|61.6|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154||||154|72.38|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|154||||154|63.14|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA [1260]|CIGNA PPO [126025]|154||||154|61.6|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|154||||154|77|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|69.3|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|69.3|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154|0|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|Self-pay|Self-pay|154||||154|30.8|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|TML [1980]|TML [198000]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNICARE [2040]|UNICARE [204000]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154|51.33|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WEB TPA [2115]|WEB TPA [211500]|154||||154|106.26|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154|51.31|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154||||154|102.62|106.26|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WORKER'S COMP [2125]|TML WC [212537]|154||||154|51.33|106.26|30.8
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AARP [1000]|AARP [100000]|673.44||||673.44|14.19|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA [1015]|AETNA [101529]|673.44||||673.44|303.05|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMBETTER [2930]|AMBETTER [293000]|673.44||||673.44|10.84|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|673.44||||673.44|336.72|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|673.44||||673.44|269.38|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|673.44||||673.44|269.38|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|673.44||||673.44|316.52|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|673.44||||673.44|276.11|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA [1260]|CIGNA PPO [126025]|673.44||||673.44|30.29|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|673.44||||673.44|14.19|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|673.44||||673.44|336.72|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|673.44||||673.44|303.05|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|673.44||||673.44|303.05|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|673.44||||673.44|0|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|Self-pay|Self-pay|673.44||||673.44|134.69|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|TML [1980]|TML [198000]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|673.44||||673.44|8.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|673.44||||673.44|14.19|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNICARE [2040]|UNICARE [204000]|673.44||||673.44|14.19|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|673.44||||673.44|14.19|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WEB TPA [2115]|WEB TPA [211500]|673.44||||673.44|464.67|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|673.44||||673.44|10.32|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|673.44||||673.44|20.64|464.67|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WORKER'S COMP [2125]|TML WC [212537]|673.44||||673.44|14.19|464.67|8.67
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AARP [1000]|AARP [100000]|615.48||||615.48|12.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA [1015]|AETNA [101529]|615.48||||615.48|276.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMBETTER [2930]|AMBETTER [293000]|615.48||||615.48|9.91|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|615.48||||615.48|307.74|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|615.48||||615.48|246.19|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|615.48||||615.48|246.19|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|615.48||||615.48|289.28|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|615.48||||615.48|252.35|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA [1260]|CIGNA PPO [126025]|615.48||||615.48|27.67|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|615.48||||615.48|12.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|615.48||||615.48|307.74|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|615.48||||615.48|276.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|615.48||||615.48|276.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|615.48||||615.48|0|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|Self-pay|Self-pay|615.48||||615.48|123.1|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|TML [1980]|TML [198000]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|615.48||||615.48|7.93|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|615.48||||615.48|12.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNICARE [2040]|UNICARE [204000]|615.48||||615.48|12.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|615.48||||615.48|12.97|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WEB TPA [2115]|WEB TPA [211500]|615.48||||615.48|424.68|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|615.48||||615.48|9.44|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|615.48||||615.48|18.88|424.68|7.93
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WORKER'S COMP [2125]|TML WC [212537]|615.48||||615.48|12.97|424.68|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AARP [1000]|AARP [100000]|361.1||||361.1|12.97|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AETNA [1015]|AETNA [101529]|361.1||||361.1|162.5|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AMBETTER [2930]|AMBETTER [293000]|361.1||||361.1|9.91|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|361.1||||361.1|180.55|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|361.1||||361.1|144.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|361.1||||361.1|144.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|361.1||||361.1|169.72|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|361.1||||361.1|148.05|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA [1260]|CIGNA PPO [126025]|361.1||||361.1|27.67|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|361.1||||361.1|12.97|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|361.1||||361.1|180.55|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|361.1||||361.1|162.5|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|361.1||||361.1|162.5|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|361.1||||361.1|0|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|Self-pay|Self-pay|361.1||||361.1|72.22|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|TML [1980]|TML [198000]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|361.1||||361.1|7.93|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|361.1||||361.1|12.97|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UNICARE [2040]|UNICARE [204000]|361.1||||361.1|12.97|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|361.1||||361.1|12.97|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WEB TPA [2115]|WEB TPA [211500]|361.1||||361.1|249.16|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|361.1||||361.1|9.44|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|361.1||||361.1|18.88|249.16|7.93
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WORKER'S COMP [2125]|TML WC [212537]|361.1||||361.1|12.97|249.16|7.93
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AARP [1000]|AARP [100000]|651.66||||651.66|11.84|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|651.66||||651.66|293.25|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|651.66||||651.66|9.05|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|651.66||||651.66|325.83|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|651.66||||651.66|260.66|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|651.66||||651.66|260.66|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|651.66||||651.66|306.28|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|651.66||||651.66|267.18|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|651.66||||651.66|25.26|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|651.66||||651.66|11.84|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|651.66||||651.66|325.83|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|651.66||||651.66|293.25|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|651.66||||651.66|293.25|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|651.66||||651.66|0|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|Self-pay|Self-pay|651.66||||651.66|130.33|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|TML [1980]|TML [198000]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|651.66||||651.66|7.24|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|651.66||||651.66|11.84|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|651.66||||651.66|11.84|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|651.66||||651.66|11.84|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|651.66||||651.66|449.65|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|651.66||||651.66|8.62|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|651.66||||651.66|17.24|449.65|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|651.66||||651.66|11.84|449.65|7.24
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AARP [1000]|AARP [100000]|616.86||||616.86|13.01|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA [1015]|AETNA [101529]|616.86||||616.86|277.59|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|616.86||||616.86|9.94|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|616.86||||616.86|308.43|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|616.86||||616.86|246.74|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|616.86||||616.86|246.74|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|616.86||||616.86|289.92|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|616.86||||616.86|252.91|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|616.86||||616.86|27.77|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|616.86||||616.86|13.01|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|616.86||||616.86|308.43|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|616.86||||616.86|277.59|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|616.86||||616.86|277.59|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|616.86||||616.86|0|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|Self-pay|Self-pay|616.86||||616.86|123.37|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|TML [1980]|TML [198000]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|616.86||||616.86|7.95|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|616.86||||616.86|13.01|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNICARE [2040]|UNICARE [204000]|616.86||||616.86|13.01|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|616.86||||616.86|13.01|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|616.86||||616.86|425.63|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|616.86||||616.86|9.47|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|616.86||||616.86|18.94|425.63|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|616.86||||616.86|13.01|425.63|7.95
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AARP [1000]|AARP [100000]|440.45||||440.45|11.11|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA [1015]|AETNA [101529]|440.45||||440.45|198.2|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMBETTER [2930]|AMBETTER [293000]|440.45||||440.45|8.48|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|440.45||||440.45|220.23|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|440.45||||440.45|176.18|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|440.45||||440.45|176.18|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|440.45||||440.45|207.01|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|440.45||||440.45|180.58|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA [1260]|CIGNA PPO [126025]|440.45||||440.45|23.67|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|440.45||||440.45|11.11|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|440.45||||440.45|220.23|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|440.45||||440.45|198.2|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|440.45||||440.45|198.2|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|440.45||||440.45|0|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|Self-pay|Self-pay|440.45||||440.45|88.09|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|TML [1980]|TML [198000]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|440.45||||440.45|6.79|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|440.45||||440.45|11.11|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNICARE [2040]|UNICARE [204000]|440.45||||440.45|11.11|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|440.45||||440.45|11.11|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WEB TPA [2115]|WEB TPA [211500]|440.45||||440.45|303.91|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|440.45||||440.45|8.08|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|440.45||||440.45|16.16|303.91|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WORKER'S COMP [2125]|TML WC [212537]|440.45||||440.45|11.11|303.91|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AARP [1000]|AARP [100000]|180.78||||180.78|11.11|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA [1015]|AETNA [101529]|180.78||||180.78|81.35|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMBETTER [2930]|AMBETTER [293000]|180.78||||180.78|8.48|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|180.78||||180.78|90.39|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180.78||||180.78|72.31|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180.78||||180.78|72.31|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180.78||||180.78|84.97|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|180.78||||180.78|74.12|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA [1260]|CIGNA PPO [126025]|180.78||||180.78|23.67|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|180.78||||180.78|11.11|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|180.78||||180.78|90.39|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180.78||||180.78|81.35|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180.78||||180.78|81.35|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180.78||||180.78|0|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|Self-pay|Self-pay|180.78||||180.78|36.16|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|TML [1980]|TML [198000]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180.78||||180.78|6.79|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180.78||||180.78|11.11|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNICARE [2040]|UNICARE [204000]|180.78||||180.78|11.11|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180.78||||180.78|11.11|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WEB TPA [2115]|WEB TPA [211500]|180.78||||180.78|124.74|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180.78||||180.78|8.08|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180.78||||180.78|16.16|124.74|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WORKER'S COMP [2125]|TML WC [212537]|180.78||||180.78|11.11|124.74|6.79
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AARP [1000]|AARP [100000]|2040.1||||2040.1|9.12|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA [1015]|AETNA [101529]|2040.1||||2040.1|918.05|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMBETTER [2930]|AMBETTER [293000]|2040.1||||2040.1|6.96|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2040.1||||2040.1|1020.05|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2040.1||||2040.1|816.04|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2040.1||||2040.1|816.04|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2040.1||||2040.1|958.85|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2040.1||||2040.1|836.44|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA [1260]|CIGNA PPO [126025]|2040.1||||2040.1|19.43|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2040.1||||2040.1|9.12|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2040.1||||2040.1|1020.05|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2040.1||||2040.1|918.05|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2040.1||||2040.1|918.05|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2040.1||||2040.1|0|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|Self-pay|Self-pay|2040.1||||2040.1|408.02|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|TML [1980]|TML [198000]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2040.1||||2040.1|5.57|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2040.1||||2040.1|9.12|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNICARE [2040]|UNICARE [204000]|2040.1||||2040.1|9.12|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2040.1||||2040.1|9.12|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WEB TPA [2115]|WEB TPA [211500]|2040.1||||2040.1|1407.67|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2040.1||||2040.1|6.63|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2040.1||||2040.1|13.26|1407.67|5.57
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WORKER'S COMP [2125]|TML WC [212537]|2040.1||||2040.1|9.12|1407.67|5.57
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AARP [1000]|AARP [100000]|264.96||||264.96|11.1|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA [1015]|AETNA [101529]|264.96||||264.96|119.23|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMBETTER [2930]|AMBETTER [293000]|264.96||||264.96|8.47|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264.96||||264.96|132.48|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264.96||||264.96|105.98|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264.96||||264.96|105.98|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264.96||||264.96|124.53|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264.96||||264.96|108.63|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA [1260]|CIGNA PPO [126025]|264.96||||264.96|23.67|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264.96||||264.96|11.1|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264.96||||264.96|132.48|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264.96||||264.96|119.23|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264.96||||264.96|119.23|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264.96||||264.96|0|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|Self-pay|Self-pay|264.96||||264.96|52.99|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|TML [1980]|TML [198000]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264.96||||264.96|6.78|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264.96||||264.96|11.1|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNICARE [2040]|UNICARE [204000]|264.96||||264.96|11.1|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264.96||||264.96|11.1|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WEB TPA [2115]|WEB TPA [211500]|264.96||||264.96|182.82|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264.96||||264.96|8.07|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264.96||||264.96|16.14|182.82|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WORKER'S COMP [2125]|TML WC [212537]|264.96||||264.96|11.1|182.82|6.78
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AARP [1000]|AARP [100000]|528.54||||528.54|11.13|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AETNA [1015]|AETNA [101529]|528.54||||528.54|237.84|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMBETTER [2930]|AMBETTER [293000]|528.54||||528.54|8.49|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528.54||||528.54|264.27|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528.54||||528.54|211.42|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528.54||||528.54|211.42|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528.54||||528.54|248.41|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528.54||||528.54|216.7|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA [1260]|CIGNA PPO [126025]|528.54||||528.54|23.73|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528.54||||528.54|11.13|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528.54||||528.54|264.27|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528.54||||528.54|237.84|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528.54||||528.54|237.84|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528.54||||528.54|0|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|Self-pay|Self-pay|528.54||||528.54|105.71|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|TML [1980]|TML [198000]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528.54||||528.54|6.8|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528.54||||528.54|11.13|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UNICARE [2040]|UNICARE [204000]|528.54||||528.54|11.13|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528.54||||528.54|11.13|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WEB TPA [2115]|WEB TPA [211500]|528.54||||528.54|364.69|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528.54||||528.54|8.09|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528.54||||528.54|16.18|364.69|6.8
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WORKER'S COMP [2125]|TML WC [212537]|528.54||||528.54|11.13|364.69|6.8
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AARP [1000]|AARP [100000]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA [1015]|AETNA [101529]|503.7||||503.7|226.67|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMBETTER [2930]|AMBETTER [293000]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|503.7||||503.7|251.85|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|503.7||||503.7|201.48|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|503.7||||503.7|201.48|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|503.7||||503.7|236.74|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|503.7||||503.7|206.52|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA [1260]|CIGNA PPO [126025]|503.7||||503.7|22.61|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|503.7||||503.7|251.85|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|503.7||||503.7|226.67|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|503.7||||503.7|226.67|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|503.7||||503.7|0|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|Self-pay|Self-pay|503.7||||503.7|100.74|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|TML [1980]|TML [198000]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNICARE [2040]|UNICARE [204000]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WEB TPA [2115]|WEB TPA [211500]|503.7||||503.7|347.55|347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|503.7||||503.7||347.55|22.61
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WORKER'S COMP [2125]|TML WC [212537]|503.7||||503.7||347.55|22.61
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AARP [1000]|AARP [100000]|549.24||||549.24|11.55|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA [1015]|AETNA [101529]|549.24||||549.24|247.16|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMBETTER [2930]|AMBETTER [293000]|549.24||||549.24|8.83|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|549.24||||549.24|274.62|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|549.24||||549.24|219.7|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|549.24||||549.24|219.7|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|549.24||||549.24|258.14|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|549.24||||549.24|225.19|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA [1260]|CIGNA PPO [126025]|549.24||||549.24|24.63|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|549.24||||549.24|11.55|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|549.24||||549.24|274.62|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|549.24||||549.24|247.16|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|549.24||||549.24|247.16|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|549.24||||549.24|0|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|Self-pay|Self-pay|549.24||||549.24|109.85|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|TML [1980]|TML [198000]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|549.24||||549.24|7.06|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|549.24||||549.24|11.55|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNICARE [2040]|UNICARE [204000]|549.24||||549.24|11.55|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|549.24||||549.24|11.55|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WEB TPA [2115]|WEB TPA [211500]|549.24||||549.24|378.98|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|549.24||||549.24|8.41|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|549.24||||549.24|16.82|378.98|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WORKER'S COMP [2125]|TML WC [212537]|549.24||||549.24|11.55|378.98|7.06
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AARP [1000]|AARP [100000]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA [1015]|AETNA [101529]|687.88||||687.88|309.55|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMBETTER [2930]|AMBETTER [293000]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|687.88||||687.88|343.94|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|687.88||||687.88|275.15|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|687.88||||687.88|275.15|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|687.88||||687.88|323.3|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|687.88||||687.88|282.03|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA [1260]|CIGNA PPO [126025]|687.88||||687.88|26.41|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|687.88||||687.88|343.94|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|687.88||||687.88|309.55|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|687.88||||687.88|309.55|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|687.88||||687.88|0|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|Self-pay|Self-pay|687.88||||687.88|137.58|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|TML [1980]|TML [198000]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNICARE [2040]|UNICARE [204000]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WEB TPA [2115]|WEB TPA [211500]|687.88||||687.88|474.64|474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|687.88||||687.88||474.64|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WORKER'S COMP [2125]|TML WC [212537]|687.88||||687.88||474.64|26.41
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AARP [1000]|AARP [100000]|58||||58|14.19|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA [1015]|AETNA [101529]|58||||58|26.1|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMBETTER [2930]|AMBETTER [293000]|58||||58|10.84|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|58||||58|29|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|23.2|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|23.2|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|27.26|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|58||||58|23.78|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA [1260]|CIGNA PPO [126025]|58||||58|30.29|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|58||||58|14.19|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|58||||58|29|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|26.1|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|26.1|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58|0|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|Self-pay|Self-pay|58||||58|11.6|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|TML [1980]|TML [198000]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58|8.67|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58|14.19|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNICARE [2040]|UNICARE [204000]|58||||58|14.19|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58|14.19|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WEB TPA [2115]|WEB TPA [211500]|58||||58|40.02|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58|10.32|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58|20.64|40.02|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WORKER'S COMP [2125]|TML WC [212537]|58||||58|14.19|40.02|8.67
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AARP [1000]|AARP [100000]|521.64||||521.64|14.85|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA [1015]|AETNA [101529]|521.64||||521.64|234.74|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMBETTER [2930]|AMBETTER [293000]|521.64||||521.64|11.34|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|521.64||||521.64|260.82|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|521.64||||521.64|208.66|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|521.64||||521.64|208.66|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|521.64||||521.64|245.17|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|521.64||||521.64|213.87|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA [1260]|CIGNA PPO [126025]|521.64||||521.64|31.64|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|521.64||||521.64|14.85|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|521.64||||521.64|260.82|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|521.64||||521.64|234.74|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|521.64||||521.64|234.74|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|521.64||||521.64|0|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|Self-pay|Self-pay|521.64||||521.64|104.33|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|TML [1980]|TML [198000]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|521.64||||521.64|9.07|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|521.64||||521.64|14.85|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNICARE [2040]|UNICARE [204000]|521.64||||521.64|14.85|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|521.64||||521.64|14.85|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WEB TPA [2115]|WEB TPA [211500]|521.64||||521.64|359.93|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|521.64||||521.64|10.8|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|521.64||||521.64|21.6|359.93|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WORKER'S COMP [2125]|TML WC [212537]|521.64||||521.64|14.85|359.93|9.07
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AARP [1000]|AARP [100000]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|85.16|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|94.63|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|75.7|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|75.7|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|88.95|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|77.59|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.94|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|94.63|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|85.16|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|85.16|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25|0|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|Self-pay|Self-pay|189.25||||189.25|37.85|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.25||||189.25||130.58|13.94
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25||130.58|13.94
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AARP [1000]|AARP [100000]|449.88||||449.88|9.49|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|202.45|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|7.85|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|224.94|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|179.95|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|179.95|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|211.44|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|184.45|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|20.19|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88|9.49|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|224.94|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|202.45|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|202.45|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88|0|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|Self-pay|Self-pay|449.88||||449.88|89.98|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88|6.28|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88|9.49|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88|9.49|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88|9.49|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|7.48|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449.88||||449.88|14.96|310.42|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88|9.49|310.42|6.28
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AARP [1000]|AARP [100000]|344.25||||344.25|11.88|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA [1015]|AETNA [101529]|344.25||||344.25|154.91|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMBETTER [2930]|AMBETTER [293000]|344.25||||344.25|9.08|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|344.25||||344.25|172.13|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344.25||||344.25|137.7|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344.25||||344.25|137.7|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344.25||||344.25|161.8|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|344.25||||344.25|141.14|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA [1260]|CIGNA PPO [126025]|344.25||||344.25|25.35|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|344.25||||344.25|11.88|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|344.25||||344.25|172.13|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344.25||||344.25|154.91|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344.25||||344.25|154.91|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344.25||||344.25|0|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|Self-pay|Self-pay|344.25||||344.25|68.85|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|TML [1980]|TML [198000]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344.25||||344.25|7.27|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344.25||||344.25|11.88|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNICARE [2040]|UNICARE [204000]|344.25||||344.25|11.88|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344.25||||344.25|11.88|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WEB TPA [2115]|WEB TPA [211500]|344.25||||344.25|237.53|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344.25||||344.25|8.65|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344.25||||344.25|17.3|237.53|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WORKER'S COMP [2125]|TML WC [212537]|344.25||||344.25|11.88|237.53|7.27
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AARP [1000]|AARP [100000]|277.38||||277.38|5.87|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA [1015]|AETNA [101529]|277.38||||277.38|124.82|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMBETTER [2930]|AMBETTER [293000]|277.38||||277.38|4.48|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.38||||277.38|138.69|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.38||||277.38|110.95|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.38||||277.38|110.95|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.38||||277.38|130.37|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.38||||277.38|113.73|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA [1260]|CIGNA PPO [126025]|277.38||||277.38|12.51|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.38||||277.38|5.87|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.38||||277.38|138.69|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.38||||277.38|124.82|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.38||||277.38|124.82|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.38||||277.38|0|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|Self-pay|Self-pay|277.38||||277.38|55.48|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|TML [1980]|TML [198000]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.38||||277.38|3.59|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.38||||277.38|5.87|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNICARE [2040]|UNICARE [204000]|277.38||||277.38|5.87|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.38||||277.38|5.87|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WEB TPA [2115]|WEB TPA [211500]|277.38||||277.38|191.39|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.38||||277.38|4.27|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.38||||277.38|8.54|191.39|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WORKER'S COMP [2125]|TML WC [212537]|277.38||||277.38|5.87|191.39|3.59
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AARP [1000]|AARP [100000]|478.25||||478.25|7.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25|5.66|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|15.76|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25|7.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25|4.53|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25|7.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25|7.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25|7.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25|5.39|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25|10.78|329.99|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25|7.39|329.99|4.53
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AARP [1000]|AARP [100000]|1433.47||||1433.47|35.83|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA [1015]|AETNA [101529]|1433.47||||1433.47|645.06|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMBETTER [2930]|AMBETTER [293000]|1433.47||||1433.47|27.37|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1433.47||||1433.47|716.74|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1433.47||||1433.47|573.39|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1433.47||||1433.47|573.39|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1433.47||||1433.47|673.73|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1433.47||||1433.47|587.72|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA [1260]|CIGNA PPO [126025]|1433.47||||1433.47|76.39|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1433.47||||1433.47|35.83|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1433.47||||1433.47|716.74|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1433.47||||1433.47|645.06|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1433.47||||1433.47|645.06|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1433.47||||1433.47|0|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|Self-pay|Self-pay|1433.47||||1433.47|286.69|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|TML [1980]|TML [198000]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1433.47||||1433.47|21.9|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1433.47||||1433.47|35.83|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNICARE [2040]|UNICARE [204000]|1433.47||||1433.47|35.83|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1433.47||||1433.47|35.83|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WEB TPA [2115]|WEB TPA [211500]|1433.47||||1433.47|989.09|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1433.47||||1433.47|26.07|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1433.47||||1433.47|52.14|989.09|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WORKER'S COMP [2125]|TML WC [212537]|1433.47||||1433.47|35.83|989.09|21.9
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AARP [1000]|AARP [100000]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|297|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|330|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|264|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|264|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|310.2|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|270.6|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|35.12|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|330|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|297|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|297|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99|0|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|Self-pay|Self-pay|659.99||||659.99|132|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99||455.39|35.12
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||455.39|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AARP [1000]|AARP [100000]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|35.12|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25||329.99|35.12
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AARP [1000]|AARP [100000]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|35.12|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25||329.99|35.12
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AARP [1000]|AARP [100000]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|35.12|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25||329.99|35.12
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AARP [1000]|AARP [100000]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|35.12|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25||329.99|35.12
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||329.99|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AARP [1000]|AARP [100000]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AETNA [1015]|AETNA [101529]|783.84||||783.84|352.73|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMBETTER [2930]|AMBETTER [293000]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.84||||783.84|391.92|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.84||||783.84|313.54|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.84||||783.84|313.54|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.84||||783.84|368.4|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.84||||783.84|321.37|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA [1260]|CIGNA PPO [126025]|783.84||||783.84|35.12|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.84||||783.84|391.92|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.84||||783.84|352.73|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.84||||783.84|352.73|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.84||||783.84|0|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|Self-pay|Self-pay|783.84||||783.84|156.77|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|TML [1980]|TML [198000]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UNICARE [2040]|UNICARE [204000]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WEB TPA [2115]|WEB TPA [211500]|783.84||||783.84|540.85|540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|783.84||||783.84||540.85|35.12
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WORKER'S COMP [2125]|TML WC [212537]|783.84||||783.84||540.85|35.12
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AARP [1000]|AARP [100000]|526||||526|16.49|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AETNA [1015]|AETNA [101529]|526||||526|236.7|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AMBETTER [2930]|AMBETTER [293000]|526||||526|14.51|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|526||||526|263|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|526||||526|210.4|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|526||||526|210.4|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|526||||526|247.22|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|526||||526|215.66|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA [1260]|CIGNA PPO [126025]|526||||526|35.12|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|526||||526|16.49|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|526||||526|263|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|526||||526|236.7|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|526||||526|236.7|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|526||||526|0|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|Self-pay|Self-pay|526||||526|105.2|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|TML [1980]|TML [198000]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|526||||526|11.61|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|526||||526|16.49|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UNICARE [2040]|UNICARE [204000]|526||||526|16.49|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|526||||526|16.49|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WEB TPA [2115]|WEB TPA [211500]|526||||526|362.94|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|526||||526|13.82|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|526||||526|27.64|362.94|11.61
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WORKER'S COMP [2125]|TML WC [212537]|526||||526|16.49|362.94|11.61
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AARP [1000]|AARP [100000]|741.06||||741.06|14.2|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA [1015]|AETNA [101529]|741.06||||741.06|333.48|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMBETTER [2930]|AMBETTER [293000]|741.06||||741.06|10.85|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|741.06||||741.06|370.53|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|741.06||||741.06|296.42|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|741.06||||741.06|296.42|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|741.06||||741.06|348.3|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|741.06||||741.06|303.83|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA [1260]|CIGNA PPO [126025]|741.06||||741.06|30.29|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|741.06||||741.06|14.2|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|741.06||||741.06|370.53|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|741.06||||741.06|333.48|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|741.06||||741.06|333.48|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|741.06||||741.06|0|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|Self-pay|Self-pay|741.06||||741.06|148.21|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|TML [1980]|TML [198000]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|741.06||||741.06|8.68|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|741.06||||741.06|14.2|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNICARE [2040]|UNICARE [204000]|741.06||||741.06|14.2|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|741.06||||741.06|14.2|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WEB TPA [2115]|WEB TPA [211500]|741.06||||741.06|511.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|741.06||||741.06|10.33|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|741.06||||741.06|20.66|511.33|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WORKER'S COMP [2125]|TML WC [212537]|741.06||||741.06|14.2|511.33|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AARP [1000]|AARP [100000]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AETNA [1015]|AETNA [101529]|741.06||||741.06|333.48|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AMBETTER [2930]|AMBETTER [293000]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|741.06||||741.06|370.53|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|741.06||||741.06|296.42|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|741.06||||741.06|296.42|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|741.06||||741.06|348.3|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|741.06||||741.06|303.83|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA [1260]|CIGNA PPO [126025]|741.06||||741.06|30.29|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|741.06||||741.06|370.53|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|741.06||||741.06|333.48|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|741.06||||741.06|333.48|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|741.06||||741.06|0|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|Self-pay|Self-pay|741.06||||741.06|148.21|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|TML [1980]|TML [198000]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UNICARE [2040]|UNICARE [204000]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WEB TPA [2115]|WEB TPA [211500]|741.06||||741.06|511.33|511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|741.06||||741.06||511.33|30.29
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WORKER'S COMP [2125]|TML WC [212537]|741.06||||741.06||511.33|30.29
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AARP [1000]|AARP [100000]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AETNA [1015]|AETNA [101529]|828||||828|372.6|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AMBETTER [2930]|AMBETTER [293000]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|828||||828|414|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|828||||828|331.2|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|828||||828|331.2|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|828||||828|389.16|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|828||||828|339.48|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA [1260]|CIGNA PPO [126025]|828||||828|33.8|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|828||||828|414|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|828||||828|372.6|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|828||||828|372.6|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|828||||828|0|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|Self-pay|Self-pay|828||||828|165.6|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|TML [1980]|TML [198000]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UNICARE [2040]|UNICARE [204000]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WEB TPA [2115]|WEB TPA [211500]|828||||828|571.32|571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|828||||828||571.32|33.8
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WORKER'S COMP [2125]|TML WC [212537]|828||||828||571.32|33.8
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AARP [1000]|AARP [100000]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|297|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|330|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|264|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|264|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|310.2|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|270.6|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|35.12|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|330|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|297|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|297|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99|0|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|Self-pay|Self-pay|659.99||||659.99|132|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99||455.39|35.12
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||455.39|35.12
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AARP [1000]|AARP [100000]|478.25||||478.25|16.49|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|215.21|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25|12.58|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|239.13|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|191.3|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|191.3|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|224.78|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|196.08|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|35.12|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25|16.49|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|239.13|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|215.21|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|215.21|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|0|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|Self-pay|Self-pay|478.25||||478.25|95.65|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25|10.06|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25|16.49|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25|16.49|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25|16.49|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25|11.98|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25|23.96|329.99|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25|16.49|329.99|10.06
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AARP [1000]|AARP [100000]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AETNA [1015]|AETNA [101529]|126||||126|56.7|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AMBETTER [2930]|AMBETTER [293000]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126||||126|63|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|50.4|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|50.4|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|59.22|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126||||126|51.66|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA [1260]|CIGNA PPO [126025]|126||||126|102.84|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126||||126|63|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|56.7|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|56.7|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|0|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|Self-pay|Self-pay|126||||126|25.2|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|TML [1980]|TML [198000]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UNICARE [2040]|UNICARE [204000]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WEB TPA [2115]|WEB TPA [211500]|126||||126|86.94|102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126||102.84|25.2
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WORKER'S COMP [2125]|TML WC [212537]|126||||126||102.84|25.2
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AARP [1000]|AARP [100000]|2239.74||||2239.74|48.24|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AETNA [1015]|AETNA [101529]|2239.74||||2239.74|1007.88|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AMBETTER [2930]|AMBETTER [293000]|2239.74||||2239.74|36.84|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2239.74||||2239.74|1119.87|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2239.74||||2239.74|895.9|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2239.74||||2239.74|895.9|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2239.74||||2239.74|1052.68|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2239.74||||2239.74|918.29|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA [1260]|CIGNA PPO [126025]|2239.74||||2239.74|102.84|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2239.74||||2239.74|48.24|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2239.74||||2239.74|1119.87|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2239.74||||2239.74|1007.88|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2239.74||||2239.74|1007.88|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2239.74||||2239.74|0|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|Self-pay|Self-pay|2239.74||||2239.74|447.95|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|TML [1980]|TML [198000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2239.74||||2239.74|29.48|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2239.74||||2239.74|48.24|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UNICARE [2040]|UNICARE [204000]|2239.74||||2239.74|48.24|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2239.74||||2239.74|48.24|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WEB TPA [2115]|WEB TPA [211500]|2239.74||||2239.74|1545.42|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2239.74||||2239.74|35.09|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2239.74||||2239.74|70.18|1545.42|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WORKER'S COMP [2125]|TML WC [212537]|2239.74||||2239.74|48.24|1545.42|29.48
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AARP [1000]|AARP [100000]|126||||126|48.24|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA [1015]|AETNA [101529]|126||||126|56.7|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMBETTER [2930]|AMBETTER [293000]|126||||126|39.13|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126||||126|63|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|50.4|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|50.4|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|59.22|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126||||126|51.66|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|126||||126|102.84|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126||||126|48.24|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126||||126|63|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|56.7|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|56.7|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|Self-pay|Self-pay|126||||126|25.2|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|TML [1980]|TML [198000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126|31.31|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126|48.24|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNICARE [2040]|UNICARE [204000]|126||||126|48.24|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126|48.24|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WEB TPA [2115]|WEB TPA [211500]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126|37.27|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126|74.54|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|126||||126|48.24|102.84|25.2
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AARP [1000]|AARP [100000]|1130.75||||1130.75|58.88|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA [1015]|AETNA [101529]|1130.75||||1130.75|508.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMBETTER [2930]|AMBETTER [293000]|1130.75||||1130.75|44.98|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.75||||1130.75|565.38|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.75||||1130.75|452.3|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.75||||1130.75|452.3|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.75||||1130.75|531.45|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.75||||1130.75|463.61|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA [1260]|CIGNA PPO [126025]|1130.75||||1130.75|125.55|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.75||||1130.75|58.88|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.75||||1130.75|565.38|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.75||||1130.75|508.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.75||||1130.75|508.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.75||||1130.75|0|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|Self-pay|Self-pay|1130.75||||1130.75|226.15|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|TML [1980]|TML [198000]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.75||||1130.75|35.99|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.75||||1130.75|58.88|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNICARE [2040]|UNICARE [204000]|1130.75||||1130.75|58.88|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.75||||1130.75|58.88|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WEB TPA [2115]|WEB TPA [211500]|1130.75||||1130.75|780.22|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.75||||1130.75|42.84|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.75||||1130.75|85.68|780.22|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WORKER'S COMP [2125]|TML WC [212537]|1130.75||||1130.75|58.88|780.22|35.99
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AARP [1000]|AARP [100000]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA [1015]|AETNA [101529]|647.22||||647.22|291.25|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMBETTER [2930]|AMBETTER [293000]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|647.22||||647.22|323.61|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|647.22||||647.22|258.89|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|647.22||||647.22|258.89|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|647.22||||647.22|304.19|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|647.22||||647.22|265.36|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA [1260]|CIGNA PPO [126025]|647.22||||647.22|249.41|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|647.22||||647.22|323.61|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|647.22||||647.22|291.25|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|647.22||||647.22|291.25|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|647.22||||647.22|0|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|Self-pay|Self-pay|647.22||||647.22|129.44|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|TML [1980]|TML [198000]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNICARE [2040]|UNICARE [204000]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WEB TPA [2115]|WEB TPA [211500]|647.22||||647.22|446.58|446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|647.22||||647.22||446.58|129.44
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WORKER'S COMP [2125]|TML WC [212537]|647.22||||647.22||446.58|129.44
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AARP [1000]|AARP [100000]|1130.75||||1130.75|58.88|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA [1015]|AETNA [101529]|1130.75||||1130.75|508.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMBETTER [2930]|AMBETTER [293000]|1130.75||||1130.75|44.98|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.75||||1130.75|565.38|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.75||||1130.75|452.3|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.75||||1130.75|452.3|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.75||||1130.75|531.45|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.75||||1130.75|463.61|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA [1260]|CIGNA PPO [126025]|1130.75||||1130.75|125.55|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.75||||1130.75|58.88|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.75||||1130.75|565.38|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.75||||1130.75|508.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.75||||1130.75|508.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.75||||1130.75|0|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|Self-pay|Self-pay|1130.75||||1130.75|226.15|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|TML [1980]|TML [198000]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.75||||1130.75|35.99|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.75||||1130.75|58.88|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNICARE [2040]|UNICARE [204000]|1130.75||||1130.75|58.88|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.75||||1130.75|58.88|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WEB TPA [2115]|WEB TPA [211500]|1130.75||||1130.75|780.22|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.75||||1130.75|42.84|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.75||||1130.75|85.68|780.22|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WORKER'S COMP [2125]|TML WC [212537]|1130.75||||1130.75|58.88|780.22|35.99
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AARP [1000]|AARP [100000]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA [1015]|AETNA [101529]|1887.49||||1887.49|849.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMBETTER [2930]|AMBETTER [293000]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1887.49||||1887.49|943.75|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1887.49||||1887.49|755|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1887.49||||1887.49|755|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1887.49||||1887.49|887.12|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1887.49||||1887.49|773.87|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA [1260]|CIGNA PPO [126025]|1887.49||||1887.49|102.84|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1887.49||||1887.49|943.75|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1887.49||||1887.49|849.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1887.49||||1887.49|849.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1887.49||||1887.49|0|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|Self-pay|Self-pay|1887.49||||1887.49|377.5|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|TML [1980]|TML [198000]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNICARE [2040]|UNICARE [204000]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WEB TPA [2115]|WEB TPA [211500]|1887.49||||1887.49|1302.37|1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1887.49||||1887.49||1302.37|102.84
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WORKER'S COMP [2125]|TML WC [212537]|1887.49||||1887.49||1302.37|102.84
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AARP [1000]|AARP [100000]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AETNA [1015]|AETNA [101529]|126||||126|56.7|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AMBETTER [2930]|AMBETTER [293000]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126||||126|63|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|50.4|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|50.4|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|59.22|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126||||126|51.66|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA [1260]|CIGNA PPO [126025]|126||||126|102.84|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126||||126|63|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|56.7|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|56.7|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|0|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|Self-pay|Self-pay|126||||126|25.2|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|TML [1980]|TML [198000]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UNICARE [2040]|UNICARE [204000]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WEB TPA [2115]|WEB TPA [211500]|126||||126|86.94|102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126||102.84|25.2
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WORKER'S COMP [2125]|TML WC [212537]|126||||126||102.84|25.2
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AARP [1000]|AARP [100000]|2239.74||||2239.74|48.24|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AETNA [1015]|AETNA [101529]|2239.74||||2239.74|1007.88|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AMBETTER [2930]|AMBETTER [293000]|2239.74||||2239.74|36.84|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2239.74||||2239.74|1119.87|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2239.74||||2239.74|895.9|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2239.74||||2239.74|895.9|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2239.74||||2239.74|1052.68|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2239.74||||2239.74|918.29|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA [1260]|CIGNA PPO [126025]|2239.74||||2239.74|102.84|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2239.74||||2239.74|48.24|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2239.74||||2239.74|1119.87|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2239.74||||2239.74|1007.88|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2239.74||||2239.74|1007.88|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2239.74||||2239.74|0|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|Self-pay|Self-pay|2239.74||||2239.74|447.95|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|TML [1980]|TML [198000]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2239.74||||2239.74|29.48|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2239.74||||2239.74|48.24|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UNICARE [2040]|UNICARE [204000]|2239.74||||2239.74|48.24|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2239.74||||2239.74|48.24|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WEB TPA [2115]|WEB TPA [211500]|2239.74||||2239.74|1545.42|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2239.74||||2239.74|35.09|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2239.74||||2239.74|70.18|1545.42|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WORKER'S COMP [2125]|TML WC [212537]|2239.74||||2239.74|48.24|1545.42|29.48
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AARP [1000]|AARP [100000]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AETNA [1015]|AETNA [101529]|1500||||1500|675|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AMBETTER [2930]|AMBETTER [293000]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1500||||1500|750|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1500||||1500|600|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1500||||1500|600|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1500||||1500|705|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1500||||1500|615|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|CIGNA [1260]|CIGNA PPO [126025]|1500||||1500|1221.52|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1500||||1500|750|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1500||||1500|675|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1500||||1500|675|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1500||||1500|0|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|Self-pay|Self-pay|1500||||1500|300|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|TML [1980]|TML [198000]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|UNICARE [2040]|UNICARE [204000]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|WEB TPA [2115]|WEB TPA [211500]|1500||||1500|1035|1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1500||||1500||1221.52|300
30687633|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 12-25 TARGETS PCR|1|WORKER'S COMP [2125]|TML WC [212537]|1500||||1500||1221.52|300
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AARP [1000]|AARP [100000]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA [1015]|AETNA [101529]|287.04||||287.04|129.17|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMBETTER [2930]|AMBETTER [293000]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|287.04||||287.04|143.52|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|287.04||||287.04|114.82|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|287.04||||287.04|114.82|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|287.04||||287.04|134.91|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|287.04||||287.04|117.69|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA [1260]|CIGNA PPO [126025]|287.04||||287.04|102.84|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|287.04||||287.04|143.52|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|287.04||||287.04|129.17|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|287.04||||287.04|129.17|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|287.04||||287.04|0|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|Self-pay|Self-pay|287.04||||287.04|57.41|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|TML [1980]|TML [198000]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNICARE [2040]|UNICARE [204000]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WEB TPA [2115]|WEB TPA [211500]|287.04||||287.04|198.06|198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|287.04||||287.04||198.06|57.41
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WORKER'S COMP [2125]|TML WC [212537]|287.04||||287.04||198.06|57.41
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AARP [1000]|AARP [100000]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA [1015]|AETNA [101529]|1367.75||||1367.75|615.49|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMBETTER [2930]|AMBETTER [293000]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1367.75||||1367.75|683.88|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1367.75||||1367.75|547.1|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1367.75||||1367.75|547.1|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1367.75||||1367.75|642.84|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1367.75||||1367.75|560.78|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA [1260]|CIGNA PPO [126025]|1367.75||||1367.75|102.84|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1367.75||||1367.75|683.88|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1367.75||||1367.75|615.49|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1367.75||||1367.75|615.49|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1367.75||||1367.75|0|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|Self-pay|Self-pay|1367.75||||1367.75|273.55|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|TML [1980]|TML [198000]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNICARE [2040]|UNICARE [204000]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WEB TPA [2115]|WEB TPA [211500]|1367.75||||1367.75|943.75|943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1367.75||||1367.75||943.75|102.84
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WORKER'S COMP [2125]|TML WC [212537]|1367.75||||1367.75||943.75|102.84
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AARP [1000]|AARP [100000]|509||||509|58.88|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA [1015]|AETNA [101529]|509||||509|229.05|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMBETTER [2930]|AMBETTER [293000]|509||||509|44.98|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|509||||509|254.5|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|509||||509|203.6|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|509||||509|203.6|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|509||||509|239.23|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|509||||509|208.69|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA [1260]|CIGNA PPO [126025]|509||||509|125.55|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|509||||509|58.88|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|509||||509|254.5|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|509||||509|229.05|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|509||||509|229.05|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|509||||509|0|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|Self-pay|Self-pay|509||||509|101.8|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|TML [1980]|TML [198000]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|509||||509|35.99|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|509||||509|58.88|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNICARE [2040]|UNICARE [204000]|509||||509|58.88|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|509||||509|58.88|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WEB TPA [2115]|WEB TPA [211500]|509||||509|351.21|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|509||||509|42.84|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|509||||509|85.68|351.21|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WORKER'S COMP [2125]|TML WC [212537]|509||||509|58.88|351.21|35.99
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AARP [1000]|AARP [100000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA [1015]|AETNA [101529]|36||||36|16.2|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMBETTER [2930]|AMBETTER [293000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|18|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|14.4|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|14.4|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|16.92|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|14.76|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|35.12|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|18|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|16.2|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|16.2|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|Self-pay|Self-pay|36||||36|7.2|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|TML [1980]|TML [198000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNICARE [2040]|UNICARE [204000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||35.12|7.2
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AARP [1000]|AARP [100000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA [1015]|AETNA [101529]|37||||37|16.65|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMBETTER [2930]|AMBETTER [293000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37||||37|18.5|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|14.8|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|14.8|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|17.39|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37||||37|15.17|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA [1260]|CIGNA PPO [126025]|37||||37|35.12|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37||||37|18.5|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|16.65|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|16.65|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|Self-pay|Self-pay|37||||37|7.4|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|TML [1980]|TML [198000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNICARE [2040]|UNICARE [204000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WEB TPA [2115]|WEB TPA [211500]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WORKER'S COMP [2125]|TML WC [212537]|37||||37||35.12|7.4
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AARP [1000]|AARP [100000]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|297|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|330|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|264|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|264|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|310.2|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|270.6|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|35.12|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|330|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|297|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|297|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99|0|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|Self-pay|Self-pay|659.99||||659.99|132|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99||455.39|35.12
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||455.39|35.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|44.82||||44.82|20.17|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMBETTER [2930]|AMBETTER [293000]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.82||||44.82|22.41|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.82||||44.82|17.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.82||||44.82|17.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.82||||44.82|21.07|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.82||||44.82|18.38|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA PPO [126025]|44.82||||44.82|17.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.82||||44.82|22.41|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.82||||44.82|20.17|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.82||||44.82|20.17|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|44.82||||44.82|8.96|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|TML [1980]|TML [198000]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.82||||44.82|6.27|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNICARE [2040]|UNICARE [204000]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.82||||44.82|0|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WEB TPA [2115]|WEB TPA [211500]|44.82||||44.82|30.93|30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.82||||44.82||30.93|6.27
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TML WC [212537]|44.82||||44.82|0|30.93|6.27
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AARP [1000]|AARP [100000]|162.84||||162.84|4.35|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA [1015]|AETNA [101529]|162.84||||162.84|73.28|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMBETTER [2930]|AMBETTER [293000]|162.84||||162.84|3.33|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|162.84||||162.84|81.42|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|162.84||||162.84|65.14|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|162.84||||162.84|65.14|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|162.84||||162.84|76.53|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|162.84||||162.84|66.76|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA [1260]|CIGNA PPO [126025]|162.84||||162.84|9.3|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|162.84||||162.84|4.35|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|162.84||||162.84|81.42|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162.84||||162.84|73.28|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162.84||||162.84|73.28|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162.84||||162.84|0|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|Self-pay|Self-pay|162.84||||162.84|32.57|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|TML [1980]|TML [198000]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|162.84||||162.84|2.66|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162.84||||162.84|4.35|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNICARE [2040]|UNICARE [204000]|162.84||||162.84|4.35|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162.84||||162.84|4.35|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WEB TPA [2115]|WEB TPA [211500]|162.84||||162.84|112.36|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162.84||||162.84|3.17|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|162.84||||162.84|6.34|112.36|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WORKER'S COMP [2125]|TML WC [212537]|162.84||||162.84|4.35|112.36|2.66
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AARP [1000]|AARP [100000]|126.25||||126.25|3.09|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA [1015]|AETNA [101529]|126.25||||126.25|56.81|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMBETTER [2930]|AMBETTER [293000]|126.25||||126.25|2.36|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126.25||||126.25|63.13|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126.25||||126.25|50.5|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126.25||||126.25|50.5|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126.25||||126.25|59.34|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126.25||||126.25|51.76|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA [1260]|CIGNA PPO [126025]|126.25||||126.25|6.59|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126.25||||126.25|3.09|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126.25||||126.25|63.13|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126.25||||126.25|56.81|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126.25||||126.25|56.81|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126.25||||126.25|0|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|Self-pay|Self-pay|126.25||||126.25|25.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|TML [1980]|TML [198000]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126.25||||126.25|1.89|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126.25||||126.25|3.09|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNICARE [2040]|UNICARE [204000]|126.25||||126.25|3.09|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126.25||||126.25|3.09|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WEB TPA [2115]|WEB TPA [211500]|126.25||||126.25|87.11|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126.25||||126.25|2.25|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126.25||||126.25|4.5|87.11|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WORKER'S COMP [2125]|TML WC [212537]|126.25||||126.25|3.09|87.11|1.89
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AARP [1000]|AARP [100000]|165.6||||165.6|4.18|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA [1015]|AETNA [101529]|165.6||||165.6|74.52|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMBETTER [2930]|AMBETTER [293000]|165.6||||165.6|3.2|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|165.6||||165.6|82.8|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165.6||||165.6|66.24|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165.6||||165.6|66.24|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165.6||||165.6|77.83|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|165.6||||165.6|67.9|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|165.6||||165.6|8.94|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|165.6||||165.6|4.18|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|165.6||||165.6|82.8|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165.6||||165.6|74.52|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165.6||||165.6|74.52|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165.6||||165.6|0|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|Self-pay|Self-pay|165.6||||165.6|33.12|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|TML [1980]|TML [198000]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165.6||||165.6|2.56|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165.6||||165.6|4.18|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNICARE [2040]|UNICARE [204000]|165.6||||165.6|4.18|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165.6||||165.6|4.18|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WEB TPA [2115]|WEB TPA [211500]|165.6||||165.6|114.26|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165.6||||165.6|3.05|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165.6||||165.6|6.1|114.26|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|165.6||||165.6|4.18|114.26|2.56
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AARP [1000]|AARP [100000]|343.62||||343.62|8.7|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA [1015]|AETNA [101529]|343.62||||343.62|154.63|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMBETTER [2930]|AMBETTER [293000]|343.62||||343.62|9.04|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|343.62||||343.62|171.81|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.62||||343.62|137.45|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.62||||343.62|137.45|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.62||||343.62|161.5|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|343.62||||343.62|140.88|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA [1260]|CIGNA PPO [126025]|343.62||||343.62|18.54|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|343.62||||343.62|8.7|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|343.62||||343.62|171.81|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.62||||343.62|154.63|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.62||||343.62|154.63|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.62||||343.62|0|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|Self-pay|Self-pay|343.62||||343.62|68.72|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|TML [1980]|TML [198000]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.62||||343.62|7.23|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.62||||343.62|8.7|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNICARE [2040]|UNICARE [204000]|343.62||||343.62|8.7|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.62||||343.62|8.7|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WEB TPA [2115]|WEB TPA [211500]|343.62||||343.62|237.1|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.62||||343.62|8.61|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.62||||343.62|17.22|237.1|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WORKER'S COMP [2125]|TML WC [212537]|343.62||||343.62|8.7|237.1|7.23
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|18.47||||18.47|8.31|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.47||||18.47|9.24|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.47||||18.47|7.39|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.47||||18.47|7.39|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.47||||18.47|8.68|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.47||||18.47|7.57|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|18.47||||18.47|7.39|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.47||||18.47|9.24|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.47||||18.47|8.31|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.47||||18.47|8.31|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|Self-pay|Self-pay|18.47||||18.47|3.69|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.47||||18.47|2.59|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.47||||18.47|0|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|18.47||||18.47|12.74|12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.47||||18.47||12.74|2.59
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|18.47||||18.47|0|12.74|2.59
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.47||||5.47|2.46|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.47||||5.47|2.74|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.47||||5.47|2.19|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.47||||5.47|2.19|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.47||||5.47|2.57|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.47||||5.47|2.24|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.47||||5.47|2.19|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.47||||5.47|2.74|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.47||||5.47|2.46|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.47||||5.47|2.46|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|5.47||||5.47|1.09|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.47||||5.47|0.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.47||||5.47|0|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.47||||5.47|3.77|3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.47||||5.47||3.77|0.77
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.47||||5.47|0|3.77|0.77
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AARP [1000]|AARP [100000]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA [1015]|AETNA [101529]|411.75||||411.75|185.29|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMBETTER [2930]|AMBETTER [293000]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|411.75||||411.75|205.88|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|411.75||||411.75|164.7|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|411.75||||411.75|164.7|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|411.75||||411.75|193.52|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|411.75||||411.75|168.82|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA [1260]|CIGNA PPO [126025]|411.75||||411.75|144.22|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|411.75||||411.75|205.88|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411.75||||411.75|185.29|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|411.75||||411.75|185.29|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|411.75||||411.75|0|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|Self-pay|Self-pay|411.75||||411.75|82.35|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|TML [1980]|TML [198000]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNICARE [2040]|UNICARE [204000]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WEB TPA [2115]|WEB TPA [211500]|411.75||||411.75|284.11|284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|411.75||||411.75||284.11|82.35
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WORKER'S COMP [2125]|TML WC [212537]|411.75||||411.75||284.11|82.35
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AARP [1000]|AARP [100000]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA [1015]|AETNA [101529]|1591||||1591|715.95|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMBETTER [2930]|AMBETTER [293000]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1591||||1591|795.5|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1591||||1591|636.4|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1591||||1591|636.4|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1591||||1591|747.77|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1591||||1591|652.31|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA [1260]|CIGNA PPO [126025]|1591||||1591|179.1|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1591||||1591|795.5|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1591||||1591|715.95|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1591||||1591|715.95|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1591||||1591|0|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|Self-pay|Self-pay|1591||||1591|318.2|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|TML [1980]|TML [198000]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNICARE [2040]|UNICARE [204000]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WEB TPA [2115]|WEB TPA [211500]|1591||||1591|1097.79|1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1591||||1591||1097.79|179.1
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WORKER'S COMP [2125]|TML WC [212537]|1591||||1591||1097.79|179.1
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AARP [1000]|AARP [100000]|836||||836|89.17|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA [1015]|AETNA [101529]|836||||836|376.2|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMBETTER [2930]|AMBETTER [293000]|836||||836|68.63|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|836||||836|418|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|836||||836|334.4|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|836||||836|334.4|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|836||||836|392.92|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|836||||836|342.76|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA [1260]|CIGNA PPO [126025]|836||||836|191.58|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|836||||836|89.17|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|836||||836|418|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|836||||836|376.2|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|836||||836|376.2|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|836||||836|0|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|Self-pay|Self-pay|836||||836|167.2|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|TML [1980]|TML [198000]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|836||||836|54.9|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|836||||836|89.17|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNICARE [2040]|UNICARE [204000]|836||||836|89.17|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|836||||836|89.17|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WEB TPA [2115]|WEB TPA [211500]|836||||836|576.84|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|836||||836|65.36|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|836||||836|130.72|576.84|54.9
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WORKER'S COMP [2125]|TML WC [212537]|836||||836|89.17|576.84|54.9
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.71||||9.71|4.37|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.71||||9.71|4.86|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.71||||9.71|3.88|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.71||||9.71|3.88|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.71||||9.71|4.56|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.71||||9.71|3.98|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.71||||9.71|3.88|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.71||||9.71|4.86|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.71||||9.71|4.37|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.71||||9.71|4.37|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|Self-pay|Self-pay|9.71||||9.71|1.94|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.71||||9.71|1.36|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.71||||9.71|0|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.71||||9.71|6.7|6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.71||||9.71||6.7|1.36
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.71||||9.71|0|6.7|1.36
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AARP [1000]|AARP [100000]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|202.73|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|225.25|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|180.2|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|180.2|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|211.74|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|184.71|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|100.13|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|225.25|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|202.73|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|202.73|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|0|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|Self-pay|Self-pay|450.5||||450.5|90.1|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|63.07|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5||310.85|63.07
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5||310.85|63.07
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AARP [1000]|AARP [100000]|183||||183|23.43|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA [1015]|AETNA [101529]|183||||183|82.35|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMBETTER [2930]|AMBETTER [293000]|183||||183|47.38|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|183||||183|91.5|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|73.2|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|73.2|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|86.01|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|183||||183|75.03|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA [1260]|CIGNA PPO [126025]|183||||183|93.21|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|183||||183|23.43|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|183||||183|91.5|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|82.35|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|82.35|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183|0|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|Self-pay|Self-pay|183||||183|36.6|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|TML [1980]|TML [198000]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183|25.62|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183|23.43|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNICARE [2040]|UNICARE [204000]|183||||183|23.43|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183|23.43|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WEB TPA [2115]|WEB TPA [211500]|183||||183|126.27|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183|45.12|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183||||183|90.25|126.27|23.43
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WORKER'S COMP [2125]|TML WC [212537]|183||||183|23.43|126.27|23.43
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AARP [1000]|AARP [100000]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AETNA [1015]|AETNA [101529]|766||||766|344.7|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AMBETTER [2930]|AMBETTER [293000]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|766||||766|383|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|766||||766|306.4|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|766||||766|306.4|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|766||||766|360.02|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|766||||766|314.06|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA [1260]|CIGNA PPO [126025]|766||||766|164.08|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|766||||766|383|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|766||||766|344.7|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|766||||766|344.7|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|766||||766|0|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|Self-pay|Self-pay|766||||766|153.2|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|TML [1980]|TML [198000]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|766||||766|107.24|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UNICARE [2040]|UNICARE [204000]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WEB TPA [2115]|WEB TPA [211500]|766||||766|528.54|528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|766||||766||528.54|107.24
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WORKER'S COMP [2125]|TML WC [212537]|766||||766||528.54|107.24
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AARP [1000]|AARP [100000]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AETNA [1015]|AETNA [101529]|416.25||||416.25|187.31|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AMBETTER [2930]|AMBETTER [293000]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|416.25||||416.25|208.13|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|416.25||||416.25|166.5|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|416.25||||416.25|166.5|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|416.25||||416.25|195.64|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|416.25||||416.25|170.66|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA [1260]|CIGNA PPO [126025]|416.25||||416.25|100.13|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|416.25||||416.25|208.13|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|416.25||||416.25|187.31|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|416.25||||416.25|187.31|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|416.25||||416.25|0|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|Self-pay|Self-pay|416.25||||416.25|83.25|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|TML [1980]|TML [198000]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|416.25||||416.25|58.28|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UNICARE [2040]|UNICARE [204000]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WEB TPA [2115]|WEB TPA [211500]|416.25||||416.25|287.21|287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|416.25||||416.25||287.21|58.28
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WORKER'S COMP [2125]|TML WC [212537]|416.25||||416.25||287.21|58.28
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AARP [1000]|AARP [100000]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AETNA [1015]|AETNA [101529]|463.1||||463.1|208.4|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AMBETTER [2930]|AMBETTER [293000]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|463.1||||463.1|231.55|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|463.1||||463.1|185.24|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|463.1||||463.1|185.24|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|463.1||||463.1|217.66|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|463.1||||463.1|189.87|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA [1260]|CIGNA PPO [126025]|463.1||||463.1|370.19|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|463.1||||463.1|231.55|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|463.1||||463.1|208.4|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|463.1||||463.1|208.4|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|463.1||||463.1|0|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|Self-pay|Self-pay|463.1||||463.1|92.62|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|TML [1980]|TML [198000]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UNICARE [2040]|UNICARE [204000]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WEB TPA [2115]|WEB TPA [211500]|463.1||||463.1|319.54|370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|463.1||||463.1||370.19|92.62
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WORKER'S COMP [2125]|TML WC [212537]|463.1||||463.1||370.19|92.62
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AARP [1000]|AARP [100000]|211.75||||211.75|23.43|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA [1015]|AETNA [101529]|211.75||||211.75|95.29|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMBETTER [2930]|AMBETTER [293000]|211.75||||211.75|50.26|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|211.75||||211.75|105.88|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211.75||||211.75|84.7|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211.75||||211.75|84.7|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211.75||||211.75|99.52|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|211.75||||211.75|86.82|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA [1260]|CIGNA PPO [126025]|211.75||||211.75|73.95|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|211.75||||211.75|23.43|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|GROUP PENSION ADMIN [1450]|GPA [145000]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|211.75||||211.75|105.88|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211.75||||211.75|95.29|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211.75||||211.75|95.29|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|PHCS [1780]|PHCS MULTIPLAN [178000]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211.75||||211.75|0|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|Self-pay|Self-pay|211.75||||211.75|42.35|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|TML [1980]|TML [198000]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211.75||||211.75|29.65|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211.75||||211.75|23.43|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNICARE [2040]|UNICARE [204000]|211.75||||211.75|23.43|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211.75||||211.75|23.43|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WEB TPA [2115]|WEB TPA [211500]|211.75||||211.75|146.11|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211.75||||211.75|47.86|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211.75||||211.75|95.73|146.11|23.43
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WORKER'S COMP [2125]|TML WC [212537]|211.75||||211.75|23.43|146.11|23.43
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AARP [1000]|AARP [100000]|942.75||||942.75|38.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA [1015]|AETNA [101529]|942.75||||942.75|424.24|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMBETTER [2930]|AMBETTER [293000]|942.75||||942.75|47.38|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|942.75||||942.75|471.38|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|942.75||||942.75|377.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|942.75||||942.75|377.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|942.75||||942.75|443.09|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|942.75||||942.75|386.53|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA [1260]|CIGNA PPO [126025]|942.75||||942.75|73.95|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|942.75||||942.75|38.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|942.75||||942.75|471.38|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|942.75||||942.75|45.12|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|942.75||||942.75|424.24|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|942.75||||942.75|424.24|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|942.75||||942.75|0|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|Self-pay|Self-pay|942.75||||942.75|188.55|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|TML [1980]|TML [198000]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|942.75||||942.75|131.99|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|942.75||||942.75|38.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNICARE [2040]|UNICARE [204000]|942.75||||942.75|38.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|942.75||||942.75|38.1|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WEB TPA [2115]|WEB TPA [211500]|942.75||||942.75|650.5|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|942.75||||942.75|47.86|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|942.75||||942.75|95.73|650.5|38.1
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WORKER'S COMP [2125]|TML WC [212537]|942.75||||942.75|38.1|650.5|38.1
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AARP [1000]|AARP [100000]|417||||417|60.45|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA [1015]|AETNA [101529]|417||||417|187.65|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMBETTER [2930]|AMBETTER [293000]|417||||417|294.16|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|417||||417|208.5|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|417||||417|166.8|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|417||||417|166.8|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|417||||417|195.99|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|417||||417|170.97|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA [1260]|CIGNA PPO [126025]|417||||417|417|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|417||||417|60.45|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|417||||417|208.5|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|417||||417|187.65|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|417||||417|187.65|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|417||||417|0|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|Self-pay|Self-pay|417||||417|83.4|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|TML [1980]|TML [198000]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|417||||417|58.38|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|417||||417|60.45|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNICARE [2040]|UNICARE [204000]|417||||417|60.45|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|417||||417|60.45|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WEB TPA [2115]|WEB TPA [211500]|417||||417|287.73|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|417||||417|280.15|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|417||||417|560.31|560.31|58.38
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WORKER'S COMP [2125]|TML WC [212537]|417||||417|60.45|560.31|58.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AARP [1000]|AARP [100000]|112||||112|12.71|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA [1015]|AETNA [101529]|112||||112|50.4|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMBETTER [2930]|AMBETTER [293000]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|112||||112|56|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112||||112|44.8|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112||||112|44.8|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112||||112|52.64|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|112||||112|45.92|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA [1260]|CIGNA PPO [126025]|112||||112|18.5|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|112||||112|12.71|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|112||||112|56|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112||||112|50.4|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112||||112|50.4|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112||||112|0|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|Self-pay|Self-pay|112||||112|22.4|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|TML [1980]|TML [198000]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112||||112|15.68|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112||||112|12.71|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNICARE [2040]|UNICARE [204000]|112||||112|12.71|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112||||112|12.71|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WEB TPA [2115]|WEB TPA [211500]|112||||112|77.28|77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112||||112||77.28|12.71
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WORKER'S COMP [2125]|TML WC [212537]|112||||112|12.71|77.28|12.71
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AARP [1000]|AARP [100000]|450.5||||450.5|23.43|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|202.73|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5|47.38|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|225.25|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|180.2|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|180.2|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|211.74|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|184.71|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|151.76|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5|23.43|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|225.25|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|202.73|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|202.73|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|0|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|Self-pay|Self-pay|450.5||||450.5|90.1|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|63.07|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5|23.43|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5|23.43|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5|23.43|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5|45.12|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5|90.25|310.85|23.43
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5|23.43|310.85|23.43
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AARP [1000]|AARP [100000]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AETNA [1015]|AETNA [101529]|202.75||||202.75|91.24|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AMBETTER [2930]|AMBETTER [293000]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|202.75||||202.75|101.38|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|202.75||||202.75|81.1|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|202.75||||202.75|81.1|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|202.75||||202.75|95.29|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|202.75||||202.75|83.13|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA [1260]|CIGNA PPO [126025]|202.75||||202.75|121.71|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|202.75||||202.75|101.38|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|202.75||||202.75|91.24|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|202.75||||202.75|91.24|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|202.75||||202.75|0|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|Self-pay|Self-pay|202.75||||202.75|40.55|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|TML [1980]|TML [198000]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|202.75||||202.75|28.39|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UNICARE [2040]|UNICARE [204000]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WEB TPA [2115]|WEB TPA [211500]|202.75||||202.75|139.9|139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|202.75||||202.75||139.9|28.39
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WORKER'S COMP [2125]|TML WC [212537]|202.75||||202.75||139.9|28.39
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AARP [1000]|AARP [100000]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA [1015]|AETNA [101529]|52||||52|23.4|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMBETTER [2930]|AMBETTER [293000]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52||||52|26|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52||||52|20.8|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52||||52|20.8|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52||||52|24.44|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52||||52|21.32|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA [1260]|CIGNA PPO [126025]|52||||52|52|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52||||52|26|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52||||52|23.4|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52||||52|23.4|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52||||52|0|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|Self-pay|Self-pay|52||||52|10.4|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|TML [1980]|TML [198000]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52||||52|7.28|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNICARE [2040]|UNICARE [204000]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WEB TPA [2115]|WEB TPA [211500]|52||||52|35.88|52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52||||52||52|7.28
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WORKER'S COMP [2125]|TML WC [212537]|52||||52||52|7.28
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AARP [1000]|AARP [100000]|388||||388|38.1|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA [1015]|AETNA [101529]|388||||388|174.6|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMBETTER [2930]|AMBETTER [293000]|388||||388|150.65|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|388||||388|194|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|388||||388|155.2|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|388||||388|155.2|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|388||||388|182.36|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|388||||388|159.08|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA [1260]|CIGNA PPO [126025]|388||||388|150.97|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|388||||388|38.1|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|388||||388|194|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|388||||388|174.6|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|388||||388|174.6|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|388||||388|0|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|Self-pay|Self-pay|388||||388|77.6|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|TML [1980]|TML [198000]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|388||||388|54.32|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|388||||388|38.1|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNICARE [2040]|UNICARE [204000]|388||||388|38.1|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|388||||388|38.1|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WEB TPA [2115]|WEB TPA [211500]|388||||388|267.72|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|388||||388|143.47|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|388||||388|286.95|286.95|38.1
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WORKER'S COMP [2125]|TML WC [212537]|388||||388|38.1|286.95|38.1
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AARP [1000]|AARP [100000]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AETNA [1015]|AETNA [101529]|327.54||||327.54|147.39|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AMBETTER [2930]|AMBETTER [293000]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|327.54||||327.54|163.77|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327.54||||327.54|131.02|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327.54||||327.54|131.02|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327.54||||327.54|153.94|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|327.54||||327.54|134.29|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA [1260]|CIGNA PPO [126025]|327.54||||327.54|327.54|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|327.54||||327.54|163.77|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327.54||||327.54|147.39|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327.54||||327.54|147.39|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327.54||||327.54|0|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|Self-pay|Self-pay|327.54||||327.54|65.51|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|TML [1980]|TML [198000]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327.54||||327.54|45.86|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UNICARE [2040]|UNICARE [204000]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WEB TPA [2115]|WEB TPA [211500]|327.54||||327.54|226|327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327.54||||327.54||327.54|45.86
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WORKER'S COMP [2125]|TML WC [212537]|327.54||||327.54||327.54|45.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AARP [1000]|AARP [100000]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AETNA [1015]|AETNA [101529]|2020.4||||2020.4|909.18|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMBETTER [2930]|AMBETTER [293000]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2020.4||||2020.4|1010.2|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2020.4||||2020.4|808.16|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2020.4||||2020.4|808.16|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2020.4||||2020.4|949.59|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2020.4||||2020.4|828.36|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA [1260]|CIGNA PPO [126025]|2020.4||||2020.4|808.16|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2020.4||||2020.4|1010.2|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2020.4||||2020.4|909.18|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2020.4||||2020.4|909.18|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|Self-pay|Self-pay|2020.4||||2020.4|404.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|TML [1980]|TML [198000]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2020.4||||2020.4|282.86|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNICARE [2040]|UNICARE [204000]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2020.4||||2020.4|0|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WEB TPA [2115]|WEB TPA [211500]|2020.4||||2020.4|1394.08|1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2020.4||||2020.4||1394.08|282.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WORKER'S COMP [2125]|TML WC [212537]|2020.4||||2020.4|0|1394.08|282.86
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14.33||||14.33|6.45|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.33||||14.33|7.17|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.33||||14.33|5.73|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.33||||14.33|5.73|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.33||||14.33|6.74|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.33||||14.33|5.88|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.33||||14.33|5.73|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.33||||14.33|7.17|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.33||||14.33|6.45|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.33||||14.33|6.45|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|Self-pay|Self-pay|14.33||||14.33|2.87|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|TML [1980]|TML [198000]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.33||||14.33|2.01|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.33||||14.33|0|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.33||||14.33|9.89|9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.33||||14.33||9.89|2.01
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.33||||14.33|0|9.89|2.01
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AARP [1000]|AARP [100000]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AETNA [1015]|AETNA [101529]|480.95||||480.95|216.43|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMBETTER [2930]|AMBETTER [293000]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|480.95||||480.95|240.48|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|480.95||||480.95|192.38|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|480.95||||480.95|192.38|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|480.95||||480.95|226.05|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|480.95||||480.95|197.19|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA [1260]|CIGNA PPO [126025]|480.95||||480.95|192.38|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|480.95||||480.95|240.48|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|480.95||||480.95|216.43|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|480.95||||480.95|216.43|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|Self-pay|Self-pay|480.95||||480.95|96.19|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|TML [1980]|TML [198000]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|480.95||||480.95|67.33|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UNICARE [2040]|UNICARE [204000]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|480.95||||480.95|0|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WEB TPA [2115]|WEB TPA [211500]|480.95||||480.95|331.86|331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|480.95||||480.95||331.86|67.33
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WORKER'S COMP [2125]|TML WC [212537]|480.95||||480.95|0|331.86|67.33
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|244.14||||244.14|109.86|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244.14||||244.14|122.07|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.14||||244.14|97.66|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.14||||244.14|97.66|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.14||||244.14|114.75|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244.14||||244.14|100.1|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|244.14||||244.14|97.66|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244.14||||244.14|122.07|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.14||||244.14|109.86|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.14||||244.14|109.86|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|244.14||||244.14|48.83|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.14||||244.14|34.18|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.14||||244.14|0|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|244.14||||244.14|168.46|168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.14||||244.14||168.46|34.18
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|244.14||||244.14|0|168.46|34.18
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|1639.75||||1639.75|737.89|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMBETTER [2930]|AMBETTER [293000]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1639.75||||1639.75|819.88|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1639.75||||1639.75|655.9|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1639.75||||1639.75|655.9|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1639.75||||1639.75|770.68|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1639.75||||1639.75|672.3|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA PPO [126025]|1639.75||||1639.75|655.9|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1639.75||||1639.75|819.88|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1639.75||||1639.75|737.89|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1639.75||||1639.75|737.89|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|1639.75||||1639.75|327.95|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TML [1980]|TML [198000]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1639.75||||1639.75|229.57|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNICARE [2040]|UNICARE [204000]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1639.75||||1639.75|0|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WEB TPA [2115]|WEB TPA [211500]|1639.75||||1639.75|1131.43|1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1639.75||||1639.75||1131.43|229.57
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TML WC [212537]|1639.75||||1639.75|0|1131.43|229.57
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|1056||||1056|475.2|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1056||||1056|528|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1056||||1056|422.4|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1056||||1056|422.4|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1056||||1056|496.32|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1056||||1056|432.96|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|1056||||1056|422.4|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1056||||1056|528|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1056||||1056|475.2|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1056||||1056|475.2|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|1056||||1056|211.2|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1056||||1056|147.84|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1056||||1056|0|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|1056||||1056|728.64|728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1056||||1056||728.64|147.84
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|1056||||1056|0|728.64|147.84
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AARP [1000]|AARP [100000]|912||||912|88.55|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|912||||912|410.4|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|912||||912|32.06|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|912||||912|456|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|912||||912|364.8|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|912||||912|364.8|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|912||||912|428.64|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|912||||912|373.92|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|912||||912|327.9|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|912||||912|88.55|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|912||||912|456|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|912||||912|410.4|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|912||||912|410.4|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|912||||912|0|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|Self-pay|Self-pay|912||||912|182.4|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|TML [1980]|TML [198000]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|912||||912|35.75|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|912||||912|88.55|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|912||||912|88.55|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|912||||912|88.55|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|912||||912|629.28|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|912||||912|30.53|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|912||||912|57.72|629.28|30.53
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|912||||912|88.55|629.28|30.53
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AARP [1000]|AARP [100000]|642||||642|57.44|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AETNA [1015]|AETNA [101529]|642||||642|288.9|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AMBETTER [2930]|AMBETTER [293000]|642||||642|22.95|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|642||||642|321|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|642||||642|256.8|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|642||||642|256.8|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|642||||642|301.74|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|642||||642|263.22|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA [1260]|CIGNA PPO [126025]|642||||642|198|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|642||||642|57.44|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|642||||642|321|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|642||||642|288.9|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|642||||642|288.9|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|642||||642|0|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|Self-pay|Self-pay|642||||642|128.4|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|TML [1980]|TML [198000]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|642||||642|26.73|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|642||||642|57.44|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UNICARE [2040]|UNICARE [204000]|642||||642|57.44|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|642||||642|57.44|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WEB TPA [2115]|WEB TPA [211500]|642||||642|442.98|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|642||||642|21.86|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|642||||642|41.46|442.98|21.86
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WORKER'S COMP [2125]|TML WC [212537]|642||||642|57.44|442.98|21.86
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AARP [1000]|AARP [100000]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA [1015]|AETNA [101529]|1120||||1120|504|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMBETTER [2930]|AMBETTER [293000]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1120||||1120|560|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1120||||1120|448|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1120||||1120|448|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1120||||1120|526.4|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1120||||1120|459.2|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA [1260]|CIGNA PPO [126025]|1120||||1120|327.9|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1120||||1120|560|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1120||||1120|504|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1120||||1120|504|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1120||||1120|0|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|Self-pay|Self-pay|1120||||1120|224|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|TML [1980]|TML [198000]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1120||||1120|84.2|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNICARE [2040]|UNICARE [204000]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WEB TPA [2115]|WEB TPA [211500]|1120||||1120|772.8|772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1120||||1120||772.8|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WORKER'S COMP [2125]|TML WC [212537]|1120||||1120||772.8|84.2
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AARP [1000]|AARP [100000]|867||||867|77.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|867||||867|77.82|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AETNA [1015]|AETNA [101529]|867||||867|390.15|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|867||||867|81.71|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|867||||867|83.99|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|867||||867|433.5|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|867||||867|77.82|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|867||||867|346.8|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|867||||867|346.8|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|867||||867|407.49|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|867||||867|355.47|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|867||||867|77.82|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|867||||867|346.8|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|867||||867|77.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|867||||867|433.5|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|867||||867|83.99|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|867||||867|390.15|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|867||||867|77.82|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|867||||867|390.15|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|867||||867|0|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|Self-pay|Self-pay|867||||867|173.4|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|TML [1980]|TML [198000]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|867||||867|28.74|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|867||||867|77.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UNICARE [2040]|UNICARE [204000]|867||||867|77.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|867||||867|77.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|867||||867|598.23|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|867||||867|77.82|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|867||||867|155.64|598.23|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|867||||867|77.64|598.23|28.74
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AARP [1000]|AARP [100000]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|1050||||1050|472.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1050||||1050|525|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1050||||1050|420|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1050||||1050|420|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1050||||1050|493.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1050||||1050|430.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|1050||||1050|420|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1050||||1050|525|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1050||||1050|472.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1050||||1050|472.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1050||||1050|0|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|Self-pay|Self-pay|1050||||1050|210|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|TML [1980]|TML [198000]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1050||||1050|39.43|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|1050||||1050|724.5|724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1050||||1050||724.5|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|1050||||1050||724.5|39.43
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AARP [1000]|AARP [100000]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AETNA [1015]|AETNA [101529]|97||||97|43.65|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AMBETTER [2930]|AMBETTER [293000]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|48.5|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|38.8|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|38.8|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|45.59|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|39.77|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|97|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|48.5|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|43.65|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|43.65|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|0|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|Self-pay|Self-pay|97||||97|19.4|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|TML [1980]|TML [198000]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|28.4|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|UNICARE [2040]|UNICARE [204000]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97||97|19.4
32073501|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT LTD 1 VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97||97|19.4
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AARP [1000]|AARP [100000]|161||||161|125.86|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AETNA [1015]|AETNA [101529]|161||||161|72.45|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|161||||161|103.76|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|161||||161|80.5|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|64.4|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|64.4|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|75.67|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|161||||161|66.01|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|161||||161|161|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|161||||161|125.86|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|161||||161|80.5|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|72.45|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|72.45|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161|0|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|Self-pay|Self-pay|161||||161|32.2|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|TML [1980]|TML [198000]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161|46.11|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161|125.86|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UNICARE [2040]|UNICARE [204000]|161||||161|125.86|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161|125.86|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|161||||161|111.09|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161|98.82|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161|197.63|197.63|32.2
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|161||||161|125.86|197.63|32.2
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AARP [1000]|AARP [100000]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AETNA [1015]|AETNA [101529]|97||||97|43.65|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AMBETTER [2930]|AMBETTER [293000]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|48.5|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|38.8|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|38.8|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|45.59|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|39.77|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|97|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|48.5|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|43.65|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|43.65|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|0|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|Self-pay|Self-pay|97||||97|19.4|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|TML [1980]|TML [198000]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|26.4|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|UNICARE [2040]|UNICARE [204000]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97||97|19.4
32073551|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 1 VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97||97|19.4
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|304.66||||304.66|137.1|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|304.66||||304.66|152.33|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304.66||||304.66|121.86|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304.66||||304.66|121.86|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304.66||||304.66|143.19|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|304.66||||304.66|124.91|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|304.66||||304.66|121.86|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|304.66||||304.66|152.33|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304.66||||304.66|137.1|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304.66||||304.66|137.1|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|Self-pay|Self-pay|304.66||||304.66|60.93|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|TML [1980]|TML [198000]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304.66||||304.66|42.65|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304.66||||304.66|0|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|304.66||||304.66|210.22|210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304.66||||304.66||210.22|42.65
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|304.66||||304.66|0|210.22|42.65
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|12.99||||12.99|5.85|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.99||||12.99|6.5|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.99||||12.99|5.2|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.99||||12.99|5.2|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.99||||12.99|6.11|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.99||||12.99|5.33|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|12.99||||12.99|5.2|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.99||||12.99|6.5|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.99||||12.99|5.85|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.99||||12.99|5.85|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|12.99||||12.99|2.6|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.99||||12.99|1.82|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.99||||12.99|0|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|12.99||||12.99|8.96|8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.99||||12.99||8.96|1.82
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|12.99||||12.99|0|8.96|1.82
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.01||||2.01|0.9|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.01||||2.01|1.01|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.01||||2.01|0.8|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.01||||2.01|0.8|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.01||||2.01|0.94|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.01||||2.01|0.82|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.01||||2.01|0.8|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.01||||2.01|1.01|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.01||||2.01|0.9|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.01||||2.01|0.9|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.01||||2.01|0.4|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.01||||2.01|0.28|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.01||||2.01|0|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.01||||2.01|1.39|1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.01||||2.01||1.39|0.28
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.01||||2.01|0|1.39|0.28
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AARP [1000]|AARP [100000]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AETNA [1015]|AETNA [101529]|16126||||16126|7256.7|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AMBETTER [2930]|AMBETTER [293000]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16126||||16126|8063|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16126||||16126|6450.4|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16126||||16126|6450.4|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16126||||16126|7579.22|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16126||||16126|6611.66|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA [1260]|CIGNA PPO [126025]|16126||||16126|8854.08|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16126||||16126|8063|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16126||||16126|7256.7|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16126||||16126|7256.7|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16126||||16126|0|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|Self-pay|Self-pay|16126||||16126|3225.2|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|TML [1980]|TML [198000]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16126||||16126|127.3|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UNICARE [2040]|UNICARE [204000]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WEB TPA [2115]|WEB TPA [211500]|16126||||16126|11126.94|11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16126||||16126||11126.94|127.3
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WORKER'S COMP [2125]|TML WC [212537]|16126||||16126||11126.94|127.3
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AARP [1000]|AARP [100000]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AETNA [1015]|AETNA [101529]|17235||||17235|7755.75|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AMBETTER [2930]|AMBETTER [293000]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17235||||17235|8617.5|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17235||||17235|6894|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17235||||17235|6894|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17235||||17235|8100.45|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17235||||17235|7066.35|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|CIGNA [1260]|CIGNA PPO [126025]|17235||||17235|6894|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17235||||17235|8617.5|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17235||||17235|7755.75|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17235||||17235|7755.75|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17235||||17235|0|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|Self-pay|Self-pay|17235||||17235|3447|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|TML [1980]|TML [198000]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17235||||17235|2412.9|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|UNICARE [2040]|UNICARE [204000]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|WEB TPA [2115]|WEB TPA [211500]|17235||||17235|11892.15|11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17235||||17235||11892.15|2412.9
32375894|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TRANSCATH THERAPY EMBOLIZATION|1|WORKER'S COMP [2125]|TML WC [212537]|17235||||17235||11892.15|2412.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|356.4||||356.4|160.38|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|356.4||||356.4|178.2|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|356.4||||356.4|142.56|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|356.4||||356.4|142.56|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|356.4||||356.4|167.51|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|356.4||||356.4|146.12|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|356.4||||356.4|142.56|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|356.4||||356.4|178.2|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|356.4||||356.4|160.38|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|356.4||||356.4|160.38|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|356.4||||356.4|71.28|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|356.4||||356.4|49.9|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|356.4||||356.4|0|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|356.4||||356.4|245.92|245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|356.4||||356.4||245.92|49.9
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|356.4||||356.4|0|245.92|49.9
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|19.14||||19.14|8.61|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.14||||19.14|9.57|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.14||||19.14|7.66|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.14||||19.14|7.66|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.14||||19.14|9|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.14||||19.14|7.85|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|19.14||||19.14|7.66|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.14||||19.14|9.57|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.14||||19.14|8.61|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.14||||19.14|8.61|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|19.14||||19.14|3.83|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.14||||19.14|2.68|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.14||||19.14|0|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|19.14||||19.14|13.21|13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.14||||19.14||13.21|2.68
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|19.14||||19.14|0|13.21|2.68
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.48||||0.48|0.22|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.48||||0.48|0.24|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.48||||0.48|0.19|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.48||||0.48|0.19|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.48||||0.48|0.23|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.48||||0.48|0.2|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.48||||0.48|0.19|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.48||||0.48|0.24|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.48||||0.48|0.22|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.48||||0.48|0.22|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.48||||0.48|0.1|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.48||||0.48|0.07|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.48||||0.48|0|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.48||||0.48|0.33|0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.48||||0.48||0.33|0.07
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.48||||0.48|0|0.33|0.07
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.68|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.52||||1.52|0.76|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.61|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.61|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.71|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.52||||1.52|0.62|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.52||||1.52|0.61|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.52||||1.52|0.76|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.68|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.68|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.3|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.21|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52|0|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.52||||1.52|1.05|1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.21
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.52||||1.52|0|1.05|0.21
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|248.61||||248.61|111.87|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMBETTER [2930]|AMBETTER [293000]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|248.61||||248.61|124.31|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248.61||||248.61|99.44|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248.61||||248.61|99.44|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248.61||||248.61|116.85|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|248.61||||248.61|101.93|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA [1260]|CIGNA PPO [126025]|248.61||||248.61|99.44|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|248.61||||248.61|124.31|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248.61||||248.61|111.87|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248.61||||248.61|111.87|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|Self-pay|Self-pay|248.61||||248.61|49.72|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|TML [1980]|TML [198000]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248.61||||248.61|34.81|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNICARE [2040]|UNICARE [204000]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248.61||||248.61|0|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WEB TPA [2115]|WEB TPA [211500]|248.61||||248.61|171.54|171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248.61||||248.61||171.54|34.81
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WORKER'S COMP [2125]|TML WC [212537]|248.61||||248.61|0|171.54|34.81
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|122.45||||122.45|55.1|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122.45||||122.45|61.23|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122.45||||122.45|48.98|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122.45||||122.45|48.98|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122.45||||122.45|57.55|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122.45||||122.45|50.2|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|122.45||||122.45|48.98|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122.45||||122.45|61.23|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122.45||||122.45|55.1|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122.45||||122.45|55.1|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|Self-pay|Self-pay|122.45||||122.45|24.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122.45||||122.45|17.14|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122.45||||122.45|0|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|122.45||||122.45|84.49|84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122.45||||122.45||84.49|17.14
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|122.45||||122.45|0|84.49|17.14
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AARP [1000]|AARP [100000]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AETNA [1015]|AETNA [101529]|721.62||||721.62|324.73|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMBETTER [2930]|AMBETTER [293000]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|721.62||||721.62|360.81|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|721.62||||721.62|288.65|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|721.62||||721.62|288.65|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|721.62||||721.62|339.16|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|721.62||||721.62|295.86|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA [1260]|CIGNA PPO [126025]|721.62||||721.62|288.65|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|721.62||||721.62|360.81|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|721.62||||721.62|324.73|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|721.62||||721.62|324.73|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|Self-pay|Self-pay|721.62||||721.62|144.32|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|TML [1980]|TML [198000]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|721.62||||721.62|101.03|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNICARE [2040]|UNICARE [204000]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|721.62||||721.62|0|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WEB TPA [2115]|WEB TPA [211500]|721.62||||721.62|497.92|497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|721.62||||721.62||497.92|101.03
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WORKER'S COMP [2125]|TML WC [212537]|721.62||||721.62|0|497.92|101.03
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.63||||18.63|8.38|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.63||||18.63|9.32|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.63||||18.63|7.45|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.63||||18.63|7.45|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.63||||18.63|8.76|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.63||||18.63|7.64|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.63||||18.63|7.45|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.63||||18.63|9.32|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.63||||18.63|8.38|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.63||||18.63|8.38|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|Self-pay|Self-pay|18.63||||18.63|3.73|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.63||||18.63|2.61|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.63||||18.63|0|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.63||||18.63|12.85|12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.63||||18.63||12.85|2.61
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.63||||18.63|0|12.85|2.61
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.4||||21.4|9.63|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.4||||21.4|10.7|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.4||||21.4|8.56|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.4||||21.4|8.56|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.4||||21.4|10.06|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.4||||21.4|8.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.4||||21.4|8.56|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.4||||21.4|10.7|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.4||||21.4|9.63|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.4||||21.4|9.63|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|Self-pay|Self-pay|21.4||||21.4|4.28|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.4||||21.4|3|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.4||||21.4|0|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.4||||21.4|14.77|14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.4||||21.4||14.77|3
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.4||||21.4|0|14.77|3
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AARP [1000]|AARP [100000]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AETNA [1015]|AETNA [101529]|142.56||||142.56|64.15|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMBETTER [2930]|AMBETTER [293000]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|142.56||||142.56|71.28|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.56||||142.56|57.02|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.56||||142.56|57.02|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.56||||142.56|67|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|142.56||||142.56|58.45|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|142.56||||142.56|57.02|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|142.56||||142.56|71.28|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.56||||142.56|64.15|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.56||||142.56|64.15|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|Self-pay|Self-pay|142.56||||142.56|28.51|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|TML [1980]|TML [198000]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.56||||142.56|19.96|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UNICARE [2040]|UNICARE [204000]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.56||||142.56|0|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WEB TPA [2115]|WEB TPA [211500]|142.56||||142.56|98.37|98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.56||||142.56||98.37|19.96
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|142.56||||142.56|0|98.37|19.96
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.16||||3.16|1.42|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.16||||3.16|1.58|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.16||||3.16|1.26|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.16||||3.16|1.26|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.16||||3.16|1.49|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.16||||3.16|1.3|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.16||||3.16|1.26|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.16||||3.16|1.58|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.16||||3.16|1.42|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.16||||3.16|1.42|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.16||||3.16|0.63|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.16||||3.16|0.44|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.16||||3.16|0|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.16||||3.16|2.18|2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.16||||3.16||2.18|0.44
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.16||||3.16|0|2.18|0.44
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AARP [1000]|AARP [100000]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AETNA [1015]|AETNA [101529]|2929||||2929|1318.05|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AMBETTER [2930]|AMBETTER [293000]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2929||||2929|1464.5|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2929||||2929|1171.6|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2929||||2929|1171.6|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2929||||2929|1376.63|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2929||||2929|1200.89|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA [1260]|CIGNA PPO [126025]|2929||||2929|1227.3|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2929||||2929|1464.5|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2929||||2929|1318.05|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2929||||2929|1318.05|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2929||||2929|0|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|Self-pay|Self-pay|2929||||2929|585.8|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|TML [1980]|TML [198000]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2929||||2929|333.08|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UNICARE [2040]|UNICARE [204000]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WEB TPA [2115]|WEB TPA [211500]|2929||||2929|2021.01|2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2929||||2929||2021.01|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WORKER'S COMP [2125]|TML WC [212537]|2929||||2929||2021.01|333.08
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AARP [1000]|AARP [100000]|2342||||2342|276.2|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AETNA [1015]|AETNA [101529]|2342||||2342|1053.9|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AMBETTER [2930]|AMBETTER [293000]|2342||||2342|380.88|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2342||||2342|1171|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2342||||2342|936.8|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2342||||2342|936.8|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2342||||2342|1100.74|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2342||||2342|960.22|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA [1260]|CIGNA PPO [126025]|2342||||2342|1227.3|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2342||||2342|276.2|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2342||||2342|1171|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2342||||2342|1053.9|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2342||||2342|1053.9|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2342||||2342|0|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|Self-pay|Self-pay|2342||||2342|468.4|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|TML [1980]|TML [198000]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2342||||2342|229.55|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2342||||2342|276.2|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UNICARE [2040]|UNICARE [204000]|2342||||2342|276.2|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2342||||2342|276.2|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WEB TPA [2115]|WEB TPA [211500]|2342||||2342|1615.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2342||||2342|341.98|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2342||||2342|683.95|1615.98|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WORKER'S COMP [2125]|TML WC [212537]|2342||||2342|276.2|1615.98|229.55
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AARP [1000]|AARP [100000]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AETNA [1015]|AETNA [101529]|5357||||5357|2410.65|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMBETTER [2930]|AMBETTER [293000]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5357||||5357|2678.5|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5357||||5357|2142.8|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5357||||5357|2142.8|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5357||||5357|2517.79|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5357||||5357|2196.37|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA [1260]|CIGNA PPO [126025]|5357||||5357|2142.8|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5357||||5357|2678.5|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5357||||5357|2410.65|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5357||||5357|2410.65|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5357||||5357|0|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|Self-pay|Self-pay|5357||||5357|1071.4|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|TML [1980]|TML [198000]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5357||||5357|679.96|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNICARE [2040]|UNICARE [204000]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WEB TPA [2115]|WEB TPA [211500]|5357||||5357|3696.33|3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5357||||5357||3696.33|679.96
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WORKER'S COMP [2125]|TML WC [212537]|5357||||5357||3696.33|679.96
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|521.34||||521.34|234.6|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|521.34||||521.34|260.67|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|521.34||||521.34|208.54|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|521.34||||521.34|208.54|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|521.34||||521.34|245.03|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|521.34||||521.34|213.75|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|521.34||||521.34|208.54|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|521.34||||521.34|260.67|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|521.34||||521.34|234.6|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|521.34||||521.34|234.6|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|521.34||||521.34|104.27|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|521.34||||521.34|72.99|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|521.34||||521.34|0|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|521.34||||521.34|359.72|359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|521.34||||521.34||359.72|72.99
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|521.34||||521.34|0|359.72|72.99
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|14.74||||14.74|6.63|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.74||||14.74|7.37|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.74||||14.74|5.9|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.74||||14.74|5.9|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.74||||14.74|6.93|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.74||||14.74|6.04|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.74||||14.74|5.9|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.74||||14.74|7.37|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.74||||14.74|6.63|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.74||||14.74|6.63|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|14.74||||14.74|2.95|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.74||||14.74|2.06|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.74||||14.74|0|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.74||||14.74|10.17|10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.74||||14.74||10.17|2.06
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.74||||14.74|0|10.17|2.06
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|411.32||||411.32|185.09|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|411.32||||411.32|205.66|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|411.32||||411.32|164.53|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|411.32||||411.32|164.53|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|411.32||||411.32|193.32|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|411.32||||411.32|168.64|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|411.32||||411.32|164.53|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|411.32||||411.32|205.66|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411.32||||411.32|185.09|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|411.32||||411.32|185.09|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|Self-pay|Self-pay|411.32||||411.32|82.26|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|411.32||||411.32|57.58|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|411.32||||411.32|0|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|411.32||||411.32|283.81|283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|411.32||||411.32||283.81|57.58
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|411.32||||411.32|0|283.81|57.58
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|57.56||||57.56|25.9|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|57.56||||57.56|28.78|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.56||||57.56|23.02|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.56||||57.56|23.02|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.56||||57.56|27.05|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|57.56||||57.56|23.6|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|57.56||||57.56|23.02|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|57.56||||57.56|28.78|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.56||||57.56|25.9|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.56||||57.56|25.9|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|57.56||||57.56|11.51|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.56||||57.56|8.06|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.56||||57.56|0|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|57.56||||57.56|39.72|39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.56||||57.56||39.72|8.06
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|57.56||||57.56|0|39.72|8.06
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|6.6||||6.6|2.97|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.6||||6.6|3.3|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.6||||6.6|2.64|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.6||||6.6|2.64|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.6||||6.6|3.1|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.6||||6.6|2.71|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.6||||6.6|2.64|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.6||||6.6|3.3|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.6||||6.6|2.97|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.6||||6.6|2.97|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|6.6||||6.6|1.32|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.6||||6.6|0.92|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.6||||6.6|0|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.6||||6.6|4.55|4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.6||||6.6||4.55|0.92
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.6||||6.6|0|4.55|0.92
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7||||7|3.15|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7||||7|3.5|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7||||7|2.8|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7||||7|2.8|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7||||7|3.29|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7||||7|2.87|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7||||7|2.8|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7||||7|3.5|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7||||7|3.15|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7||||7|3.15|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|7||||7|1.4|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7||||7|0.98|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7||||7|0|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7||||7|4.83|4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7||||7||4.83|0.98
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7||||7|0|4.83|0.98
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.11||||7.11|3.2|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.11||||7.11|3.56|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.11||||7.11|2.84|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.11||||7.11|2.84|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.11||||7.11|3.34|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.11||||7.11|2.92|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.11||||7.11|2.84|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.11||||7.11|3.56|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.11||||7.11|3.2|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.11||||7.11|3.2|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|7.11||||7.11|1.42|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.11||||7.11|1|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.11||||7.11|0|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.11||||7.11|4.91|4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.11||||7.11||4.91|1
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.11||||7.11|0|4.91|1
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AARP [1000]|AARP [100000]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AETNA [1015]|AETNA [101529]|2726||||2726|673|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMBETTER [2930]|AMBETTER [293000]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2726||||2726|1363|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2726||||2726|1090.4|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2726||||2726|1090.4|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2726||||2726|1281.22|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2726||||2726|1117.66|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA [1260]|CIGNA PPO [126025]|2726||||2726|1090.4|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2726||||2726|1363|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2726||||2726|673|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2726||||2726|673|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2726||||2726|0|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|Self-pay|Self-pay|2726||||2726|545.2|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|TML [1980]|TML [198000]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2726||||2726|381.64|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UNICARE [2040]|UNICARE [204000]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WEB TPA [2115]|WEB TPA [211500]|2726||||2726|1880.94|1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2726||||2726||1880.94|381.64
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WORKER'S COMP [2125]|TML WC [212537]|2726||||2726||1880.94|381.64
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AARP [1000]|AARP [100000]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AETNA [1015]|AETNA [101529]|1962.2||||1962.2|673|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AMBETTER [2930]|AMBETTER [293000]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1962.2||||1962.2|981.1|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1962.2||||1962.2|784.88|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1962.2||||1962.2|784.88|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1962.2||||1962.2|922.23|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1962.2||||1962.2|804.5|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA [1260]|CIGNA PPO [126025]|1962.2||||1962.2|784.88|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1962.2||||1962.2|981.1|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1962.2||||1962.2|673|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1962.2||||1962.2|673|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1962.2||||1962.2|0|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|Self-pay|Self-pay|1962.2||||1962.2|392.44|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|TML [1980]|TML [198000]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1962.2||||1962.2|274.71|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UNICARE [2040]|UNICARE [204000]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WEB TPA [2115]|WEB TPA [211500]|1962.2||||1962.2|1353.92|1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1962.2||||1962.2||1353.92|274.71
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WORKER'S COMP [2125]|TML WC [212537]|1962.2||||1962.2||1353.92|274.71
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.48||||18.48|8.32|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.48||||18.48|9.24|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.48||||18.48|7.39|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.48||||18.48|7.39|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.48||||18.48|8.69|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.48||||18.48|7.58|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.48||||18.48|7.39|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.48||||18.48|9.24|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.48||||18.48|8.32|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.48||||18.48|8.32|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|18.48||||18.48|3.7|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.48||||18.48|2.59|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.48||||18.48|0|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.48||||18.48|12.75|12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.48||||18.48||12.75|2.59
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.48||||18.48|0|12.75|2.59
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.67||||3.67|1.65|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.67||||3.67|1.84|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.67||||3.67|1.47|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.67||||3.67|1.47|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.67||||3.67|1.72|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.67||||3.67|1.5|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.67||||3.67|1.47|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.67||||3.67|1.84|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.67||||3.67|1.65|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.67||||3.67|1.65|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|3.67||||3.67|0.73|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.67||||3.67|0.51|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.67||||3.67|0|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.67||||3.67|2.53|2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.67||||3.67||2.53|0.51
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.67||||3.67|0|2.53|0.51
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|7553||||7553|424.05|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|7553||||7553|673|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|7553||||7553|194.65|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7553||||7553|3776.5|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7553||||7553|3021.2|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7553||||7553|3021.2|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7553||||7553|3549.91|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7553||||7553|3096.73|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|7553||||7553|873.89|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7553||||7553|424.05|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7553||||7553|3776.5|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7553||||7553|673|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7553||||7553|673|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7553||||7553|0|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|Self-pay|Self-pay|7553||||7553|1510.6|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|TML [1980]|TML [198000]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7553||||7553|252.74|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7553||||7553|424.05|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|7553||||7553|424.05|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7553||||7553|424.05|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|7553||||7553|5211.57|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7553||||7553|185.38|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7553||||7553|370.75|5211.57|185.38
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|7553||||7553|424.05|5211.57|185.38
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AARP [1000]|AARP [100000]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AETNA [1015]|AETNA [101529]|135.28||||135.28|60.88|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMBETTER [2930]|AMBETTER [293000]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|135.28||||135.28|67.64|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135.28||||135.28|54.11|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135.28||||135.28|54.11|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135.28||||135.28|63.58|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|135.28||||135.28|55.46|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA [1260]|CIGNA PPO [126025]|135.28||||135.28|54.11|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|135.28||||135.28|67.64|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135.28||||135.28|60.88|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135.28||||135.28|60.88|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|Self-pay|Self-pay|135.28||||135.28|27.06|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|TML [1980]|TML [198000]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135.28||||135.28|18.94|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNICARE [2040]|UNICARE [204000]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135.28||||135.28|0|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WEB TPA [2115]|WEB TPA [211500]|135.28||||135.28|93.34|93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135.28||||135.28||93.34|18.94
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WORKER'S COMP [2125]|TML WC [212537]|135.28||||135.28|0|93.34|18.94
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|6755||||6755|673|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6755||||6755|3377.5|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6755||||6755|2702|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6755||||6755|2702|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6755||||6755|3174.85|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6755||||6755|2769.55|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|6755||||6755|873.89|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6755||||6755|3377.5|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6755||||6755|673|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6755||||6755|673|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6755||||6755|0|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|6755||||6755|1351|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|TML [1980]|TML [198000]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6755||||6755|252.74|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|6755||||6755|4660.95|4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6755||||6755||4660.95|252.74
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|6755||||6755||4660.95|252.74
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|5578||||5578|371.44|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|5578||||5578|673|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5578||||5578|350.51|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5578||||5578|2789|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5578||||5578|2231.2|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5578||||5578|2231.2|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5578||||5578|2621.66|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5578||||5578|2286.98|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5578||||5578|1282.9|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5578||||5578|371.44|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5578||||5578|2789|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5578||||5578|673|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5578||||5578|673|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5578||||5578|0|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|Self-pay|Self-pay|5578||||5578|1115.6|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|TML [1980]|TML [198000]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5578||||5578|215.51|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5578||||5578|371.44|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5578||||5578|371.44|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5578||||5578|371.44|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5578||||5578|3848.82|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5578||||5578|333.81|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5578||||5578|667.63|3848.82|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5578||||5578|371.44|3848.82|215.51
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|6326||||6326|411.68|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|6326||||6326|673|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|6326||||6326|180.33|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6326||||6326|3163|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6326||||6326|2530.4|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6326||||6326|2530.4|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6326||||6326|2973.22|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6326||||6326|2593.66|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|6326||||6326|873.89|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6326||||6326|411.68|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6326||||6326|3163|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6326||||6326|673|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6326||||6326|673|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6326||||6326|0|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|6326||||6326|1265.2|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|TML [1980]|TML [198000]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6326||||6326|252.74|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6326||||6326|411.68|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|6326||||6326|411.68|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6326||||6326|411.68|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|6326||||6326|4364.94|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6326||||6326|171.75|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6326||||6326|343.49|4364.94|171.75
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|6326||||6326|411.68|4364.94|171.75
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AARP [1000]|AARP [100000]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|5578||||5578|673|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5578||||5578|2789|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5578||||5578|2231.2|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5578||||5578|2231.2|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5578||||5578|2621.66|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5578||||5578|2286.98|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5578||||5578|1282.9|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5578||||5578|2789|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5578||||5578|673|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5578||||5578|673|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5578||||5578|0|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|Self-pay|Self-pay|5578||||5578|1115.6|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|TML [1980]|TML [198000]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5578||||5578|210.5|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5578||||5578|3848.82|3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5578||||5578||3848.82|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5578||||5578||3848.82|210.5
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AARP [1000]|AARP [100000]|7074||||7074|424.05|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AETNA [1015]|AETNA [101529]|7074||||7074|673|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AMBETTER [2930]|AMBETTER [293000]|7074||||7074|194.65|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7074||||7074|3537|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7074||||7074|2829.6|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7074||||7074|2829.6|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7074||||7074|3324.78|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7074||||7074|2900.34|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA PPO [126025]|7074||||7074|873.89|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7074||||7074|424.05|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7074||||7074|3537|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7074||||7074|673|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7074||||7074|673|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7074||||7074|0|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|Self-pay|Self-pay|7074||||7074|1414.8|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|TML [1980]|TML [198000]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7074||||7074|252.74|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7074||||7074|424.05|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UNICARE [2040]|UNICARE [204000]|7074||||7074|424.05|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7074||||7074|424.05|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WEB TPA [2115]|WEB TPA [211500]|7074||||7074|4881.06|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7074||||7074|185.38|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7074||||7074|370.75|4881.06|185.38
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TML WC [212537]|7074||||7074|424.05|4881.06|185.38
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AARP [1000]|AARP [100000]|2515||||2515|603.23|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AETNA [1015]|AETNA [101529]|2515||||2515|673|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AMBETTER [2930]|AMBETTER [293000]|2515||||2515|350.51|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2515||||2515|1257.5|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2515||||2515|1006|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2515||||2515|1006|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2515||||2515|1182.05|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2515||||2515|1031.15|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA PPO [126025]|2515||||2515|1282.9|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2515||||2515|603.23|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2515||||2515|1257.5|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2515||||2515|673|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2515||||2515|673|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2515||||2515|0|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|Self-pay|Self-pay|2515||||2515|503|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|TML [1980]|TML [198000]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2515||||2515|252.74|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2515||||2515|603.23|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UNICARE [2040]|UNICARE [204000]|2515||||2515|603.23|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2515||||2515|603.23|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WEB TPA [2115]|WEB TPA [211500]|2515||||2515|1735.35|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2515||||2515|333.81|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2515||||2515|667.63|1735.35|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TML WC [212537]|2515||||2515|603.23|1735.35|252.74
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.74|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMBETTER [2930]|AMBETTER [293000]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.65||||1.65|0.83|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.66|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.66|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|0.78|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.65||||1.65|0.68|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1.65||||1.65|0.66|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.65||||1.65|0.83|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.74|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.74|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|1.65||||1.65|0.33|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|TML [1980]|TML [198000]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.23|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNICARE [2040]|UNICARE [204000]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65|0|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WEB TPA [2115]|WEB TPA [211500]|1.65||||1.65|1.14|1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.23
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1.65||||1.65|0|1.14|0.23
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.88||||4.88|2.2|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.88||||4.88|2.44|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.88||||4.88|1.95|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.88||||4.88|1.95|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.88||||4.88|2.29|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.88||||4.88|2|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.88||||4.88|1.95|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.88||||4.88|2.44|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.88||||4.88|2.2|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.88||||4.88|2.2|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|4.88||||4.88|0.98|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.88||||4.88|0.68|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.88||||4.88|0|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.88||||4.88|3.37|3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.88||||4.88||3.37|0.68
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.88||||4.88|0|3.37|0.68
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.82||||10.82|4.87|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.82||||10.82|5.41|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.82||||10.82|4.33|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.82||||10.82|4.33|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.82||||10.82|5.09|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.82||||10.82|4.44|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.82||||10.82|4.33|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.82||||10.82|5.41|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.82||||10.82|4.87|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.82||||10.82|4.87|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|10.82||||10.82|2.16|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.82||||10.82|1.51|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.82||||10.82|0|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.82||||10.82|7.47|7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.82||||10.82||7.47|1.51
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.82||||10.82|0|7.47|1.51
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|79.07||||79.07|35.58|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.07||||79.07|39.54|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.07||||79.07|31.63|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.07||||79.07|31.63|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.07||||79.07|37.16|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.07||||79.07|32.42|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|79.07||||79.07|31.63|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.07||||79.07|39.54|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.07||||79.07|35.58|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.07||||79.07|35.58|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|79.07||||79.07|15.81|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.07||||79.07|11.07|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.07||||79.07|0|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|79.07||||79.07|54.56|54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.07||||79.07||54.56|11.07
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|79.07||||79.07|0|54.56|11.07
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AARP [1000]|AARP [100000]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AETNA [1015]|AETNA [101529]|6.47||||6.47|2.91|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.47||||6.47|3.24|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.47||||6.47|2.59|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.47||||6.47|2.59|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.47||||6.47|3.04|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.47||||6.47|2.65|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.47||||6.47|2.59|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.47||||6.47|3.24|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.47||||6.47|2.91|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.47||||6.47|2.91|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|Self-pay|Self-pay|6.47||||6.47|1.29|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|TML [1980]|TML [198000]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.47||||6.47|0.91|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|UNICARE [2040]|UNICARE [204000]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.47||||6.47|0|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.47||||6.47|4.46|4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.47||||6.47||4.46|0.91
35942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.47||||6.47|0|4.46|0.91
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AARP [1000]|AARP [100000]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA [1015]|AETNA [101529]|1959.6||||1959.6|881.82|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMBETTER [2930]|AMBETTER [293000]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1959.6||||1959.6|979.8|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1959.6||||1959.6|783.84|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1959.6||||1959.6|783.84|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1959.6||||1959.6|921.01|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1959.6||||1959.6|803.44|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA [1260]|CIGNA PPO [126025]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1959.6||||1959.6|979.8|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1959.6||||1959.6|881.82|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1959.6||||1959.6|881.82|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1959.6||||1959.6|0|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|Self-pay|Self-pay|1959.6||||1959.6|391.92|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|TML [1980]|TML [198000]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1959.6||||1959.6|263.85|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNICARE [2040]|UNICARE [204000]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WEB TPA [2115]|WEB TPA [211500]|1959.6||||1959.6|1254.14|1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1959.6||||1959.6||1254.14|263.85
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WORKER'S COMP [2125]|TML WC [212537]|1959.6||||1959.6||1254.14|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AARP [1000]|AARP [100000]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AETNA [1015]|AETNA [101529]|3827.7||||3827.7|1722.47|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AMBETTER [2930]|AMBETTER [293000]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3827.7||||3827.7|1913.85|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3827.7||||3827.7|1531.08|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3827.7||||3827.7|1531.08|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3827.7||||3827.7|1799.02|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3827.7||||3827.7|1569.36|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA [1260]|CIGNA PPO [126025]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3827.7||||3827.7|1913.85|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3827.7||||3827.7|1722.47|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3827.7||||3827.7|1722.47|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3827.7||||3827.7|0|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|Self-pay|Self-pay|3827.7||||3827.7|765.54|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|TML [1980]|TML [198000]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3827.7||||3827.7|263.85|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UNICARE [2040]|UNICARE [204000]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WEB TPA [2115]|WEB TPA [211500]|3827.7||||3827.7|2449.73|2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3827.7||||3827.7||2449.73|263.85
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WORKER'S COMP [2125]|TML WC [212537]|3827.7||||3827.7||2449.73|263.85
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AARP [1000]|AARP [100000]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AETNA [1015]|AETNA [101529]|40||||40|18|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AMBETTER [2930]|AMBETTER [293000]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40||||40|20|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|16|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|16|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|18.8|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40||||40|16.4|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|CIGNA [1260]|CIGNA PPO [126025]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40||||40|20|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|18|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|18|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40|0|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|Self-pay|Self-pay|40||||40|8|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|TML [1980]|TML [198000]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40|5.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|UNICARE [2040]|UNICARE [204000]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|WEB TPA [2115]|WEB TPA [211500]|40||||40|25.6|25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40||25.6|5.6
36020560|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES|1|WORKER'S COMP [2125]|TML WC [212537]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AARP [1000]|AARP [100000]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AETNA [1015]|AETNA [101529]|40||||40|18|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AMBETTER [2930]|AMBETTER [293000]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40||||40|20|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|16|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|16|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|18.8|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40||||40|16.4|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|CIGNA [1260]|CIGNA PPO [126025]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40||||40|20|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|18|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|18|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40|0|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|Self-pay|Self-pay|40||||40|8|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|TML [1980]|TML [198000]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40|5.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|UNICARE [2040]|UNICARE [204000]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|WEB TPA [2115]|WEB TPA [211500]|40||||40|25.6|25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40||25.6|5.6
36020561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NDL INSERT W/O INJECTION 3+MUSCLES|1|WORKER'S COMP [2125]|TML WC [212537]|40||||40||25.6|5.6
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AARP [1000]|AARP [100000]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA [1015]|AETNA [101529]|3390.2||||3390.2|1525.59|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMBETTER [2930]|AMBETTER [293000]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3390.2||||3390.2|1695.1|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3390.2||||3390.2|1356.08|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3390.2||||3390.2|1356.08|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3390.2||||3390.2|1593.39|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3390.2||||3390.2|1389.98|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA [1260]|CIGNA PPO [126025]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3390.2||||3390.2|1695.1|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3390.2||||3390.2|1525.59|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3390.2||||3390.2|1525.59|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3390.2||||3390.2|0|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|Self-pay|Self-pay|3390.2||||3390.2|678.04|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|TML [1980]|TML [198000]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3390.2||||3390.2|263.85|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNICARE [2040]|UNICARE [204000]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WEB TPA [2115]|WEB TPA [211500]|3390.2||||3390.2|2169.73|2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3390.2||||3390.2||2169.73|263.85
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WORKER'S COMP [2125]|TML WC [212537]|3390.2||||3390.2||2169.73|263.85
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AARP [1000]|AARP [100000]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|3671.79||||3671.79|1652.31|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AMBETTER [2930]|AMBETTER [293000]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.79||||3671.79|1835.9|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.79||||3671.79|1468.72|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.79||||3671.79|1468.72|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.79||||3671.79|1725.74|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.79||||3671.79|1505.43|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|CIGNA [1260]|CIGNA PPO [126025]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.79||||3671.79|1835.9|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.79||||3671.79|1652.31|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.79||||3671.79|1652.31|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.79||||3671.79|0|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|Self-pay|Self-pay|3671.79||||3671.79|734.36|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|TML [1980]|TML [198000]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.79||||3671.79|353.3|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|UNICARE [2040]|UNICARE [204000]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|WEB TPA [2115]|WEB TPA [211500]|3671.79||||3671.79|2349.95|2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.79||||3671.79||2349.95|353.3
36031625|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRONCHIAL/ENDOBRNCL BIOPSY(S)|1|WORKER'S COMP [2125]|TML WC [212537]|3671.79||||3671.79||2349.95|353.3
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AARP [1000]|AARP [100000]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AETNA [1015]|AETNA [101529]|3671.32||||3671.32|1652.09|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AMBETTER [2930]|AMBETTER [293000]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.32||||3671.32|1835.66|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.32||||3671.32|1468.53|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.32||||3671.32|1468.53|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.32||||3671.32|1725.52|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.32||||3671.32|1505.24|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|CIGNA [1260]|CIGNA PPO [126025]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.32||||3671.32|1835.66|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.32||||3671.32|1652.09|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.32||||3671.32|1652.09|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.32||||3671.32|0|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|Self-pay|Self-pay|3671.32||||3671.32|734.26|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|TML [1980]|TML [198000]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.32||||3671.32|513.98|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|UNICARE [2040]|UNICARE [204000]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|WEB TPA [2115]|WEB TPA [211500]|3671.32||||3671.32|2349.64|2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.32||||3671.32||2349.64|513.98
36036010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO CATH SUP/INF VENA CAVA|1|WORKER'S COMP [2125]|TML WC [212537]|3671.32||||3671.32||2349.64|513.98
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AARP [1000]|AARP [100000]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA [1015]|AETNA [101529]|82||||82|36.9|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMBETTER [2930]|AMBETTER [293000]|82||||82|3.15|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82||||82|41|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|32.8|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|32.8|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|38.54|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82||||82|33.62|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA [1260]|CIGNA PPO [126025]|82||||82|6.45|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82||||82|41|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|36.9|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|36.9|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|0|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|Self-pay|Self-pay|82||||82|16.4|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|TML [1980]|TML [198000]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|11.48|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNICARE [2040]|UNICARE [204000]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WEB TPA [2115]|WEB TPA [211500]|82||||82|56.58|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82|3|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82|6|56.58|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WORKER'S COMP [2125]|TML WC [212537]|82||||82|3|56.58|3
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AARP [1000]|AARP [100000]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AETNA [1015]|AETNA [101529]|7477||||7477|3364.65|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMBETTER [2930]|AMBETTER [293000]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7477||||7477|3738.5|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7477||||7477|2990.8|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7477||||7477|2990.8|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7477||||7477|3514.19|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7477||||7477|3065.57|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA [1260]|CIGNA PPO [126025]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7477||||7477|3738.5|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7477||||7477|3364.65|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7477||||7477|3364.65|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7477||||7477|0|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|Self-pay|Self-pay|7477||||7477|1495.4|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|TML [1980]|TML [198000]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7477||||7477|405.18|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UNICARE [2040]|UNICARE [204000]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WEB TPA [2115]|WEB TPA [211500]|7477||||7477|4785.28|4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7477||||7477||4785.28|405.18
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WORKER'S COMP [2125]|TML WC [212537]|7477||||7477||4785.28|405.18
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AARP [1000]|AARP [100000]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AETNA [1015]|AETNA [101529]|7477||||7477|3364.65|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMBETTER [2930]|AMBETTER [293000]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7477||||7477|3738.5|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7477||||7477|2990.8|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7477||||7477|2990.8|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7477||||7477|3514.19|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7477||||7477|3065.57|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA PPO [126025]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7477||||7477|3738.5|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7477||||7477|3364.65|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7477||||7477|3364.65|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7477||||7477|0|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|Self-pay|Self-pay|7477||||7477|1495.4|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|TML [1980]|TML [198000]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7477||||7477|353.3|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UNICARE [2040]|UNICARE [204000]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WEB TPA [2115]|WEB TPA [211500]|7477||||7477|4785.28|4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7477||||7477||4785.28|353.3
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TML WC [212537]|7477||||7477||4785.28|353.3
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AARP [1000]|AARP [100000]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA [1015]|AETNA [101529]|324||||324|145.8|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMBETTER [2930]|AMBETTER [293000]|324||||324|106.59|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|324||||324|162|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324||||324|129.6|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324||||324|59|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324||||324|69|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|324||||324|58|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA [1260]|CIGNA PPO [126025]|324||||324|324|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|324||||324|162|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324||||324|145.8|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324||||324|145.8|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|Self-pay|Self-pay|324||||324|64.8|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|TML [1980]|TML [198000]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324||||324|45.36|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNICARE [2040]|UNICARE [204000]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324||||324|0|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WEB TPA [2115]|WEB TPA [211500]|324||||324|223.56|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324||||324|101.52|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324||||324|203.04|324|45.36
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WORKER'S COMP [2125]|TML WC [212537]|324||||324|0|324|45.36
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AARP [1000]|AARP [100000]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AETNA [1015]|AETNA [101529]|3510.05||||3510.05|1579.52|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AMBETTER [2930]|AMBETTER [293000]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3510.05||||3510.05|1755.03|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3510.05||||3510.05|1404.02|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3510.05||||3510.05|1404.02|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3510.05||||3510.05|1649.72|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3510.05||||3510.05|1439.12|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|CIGNA [1260]|CIGNA PPO [126025]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3510.05||||3510.05|1755.03|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3510.05||||3510.05|1579.52|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3510.05||||3510.05|1579.52|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3510.05||||3510.05|0|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|Self-pay|Self-pay|3510.05||||3510.05|702.01|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|TML [1980]|TML [198000]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3510.05||||3510.05|263.85|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|UNICARE [2040]|UNICARE [204000]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|WEB TPA [2115]|WEB TPA [211500]|3510.05||||3510.05|2246.43|2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3510.05||||3510.05||2246.43|263.85
36036901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SP INTRO CATH DIALYSIS CIRCUIT|1|WORKER'S COMP [2125]|TML WC [212537]|3510.05||||3510.05||2246.43|263.85
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AARP [1000]|AARP [100000]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AETNA [1015]|AETNA [101529]|39033.9||||39033.9|17565.26|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AMBETTER [2930]|AMBETTER [293000]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39033.9||||39033.9|19516.95|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39033.9||||39033.9|15613.56|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39033.9||||39033.9|15613.56|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39033.9||||39033.9|18345.93|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39033.9||||39033.9|16003.9|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|CIGNA [1260]|CIGNA PPO [126025]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|GROUP PENSION ADMIN [1450]|GPA [145000]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39033.9||||39033.9|19516.95|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39033.9||||39033.9|17565.26|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39033.9||||39033.9|17565.26|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|PHCS [1780]|PHCS MULTIPLAN [178000]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39033.9||||39033.9|0|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|Self-pay|Self-pay|39033.9||||39033.9|7806.78|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|TML [1980]|TML [198000]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39033.9||||39033.9|1028.6|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|UNICARE [2040]|UNICARE [204000]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|WEB TPA [2115]|WEB TPA [211500]|39033.9||||39033.9|24981.7|24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39033.9||||39033.9||24981.7|1028.6
36036902|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-PTA DIALYSIS-S/R|1|WORKER'S COMP [2125]|TML WC [212537]|39033.9||||39033.9||24981.7|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AARP [1000]|AARP [100000]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AETNA [1015]|AETNA [101529]|46518.06||||46518.06|20933.13|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AMBETTER [2930]|AMBETTER [293000]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46518.06||||46518.06|23259.03|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46518.06||||46518.06|18607.22|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46518.06||||46518.06|18607.22|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46518.06||||46518.06|21863.49|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46518.06||||46518.06|19072.4|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|CIGNA [1260]|CIGNA PPO [126025]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|GROUP PENSION ADMIN [1450]|GPA [145000]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46518.06||||46518.06|23259.03|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46518.06||||46518.06|20933.13|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46518.06||||46518.06|20933.13|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|PHCS [1780]|PHCS MULTIPLAN [178000]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46518.06||||46518.06|0|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|Self-pay|Self-pay|46518.06||||46518.06|9303.61|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|TML [1980]|TML [198000]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46518.06||||46518.06|1028.6|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|UNICARE [2040]|UNICARE [204000]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|WEB TPA [2115]|WEB TPA [211500]|46518.06||||46518.06|29771.56|29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46518.06||||46518.06||29771.56|1028.6
36036905|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVF-DECLOT/PTA DIALYSIS-S/R|1|WORKER'S COMP [2125]|TML WC [212537]|46518.06||||46518.06||29771.56|1028.6
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AARP [1000]|AARP [100000]|5078.62||||5078.62|1712|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|5078.62||||5078.62|2285.38|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AMBETTER [2930]|AMBETTER [293000]|5078.62||||5078.62|1130.43|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5078.62||||5078.62|2539.31|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5078.62||||5078.62|2031.45|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5078.62||||5078.62|2031.45|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5078.62||||5078.62|2386.95|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5078.62||||5078.62|2082.23|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA [1260]|CIGNA PPO [126025]|5078.62||||5078.62|1985|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5078.62||||5078.62|1712|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5078.62||||5078.62|2539.31|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5078.62||||5078.62|1076.6|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5078.62||||5078.62|2285.38|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5078.62||||5078.62|2285.38|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5078.62||||5078.62|0|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|Self-pay|Self-pay|5078.62||||5078.62|1015.72|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|TML [1980]|TML [198000]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5078.62||||5078.62|353.3|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5078.62||||5078.62|1712|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UNICARE [2040]|UNICARE [204000]|5078.62||||5078.62|1712|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5078.62||||5078.62|1712|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WEB TPA [2115]|WEB TPA [211500]|5078.62||||5078.62|3250.32|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5078.62||||5078.62|940.33|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5078.62||||5078.62|1880.67|3250.32|353.3
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WORKER'S COMP [2125]|TML WC [212537]|5078.62||||5078.62|1712|3250.32|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AARP [1000]|AARP [100000]|5356.87||||5356.87|1712|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AETNA [1015]|AETNA [101529]|5356.87||||5356.87|2410.59|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AMBETTER [2930]|AMBETTER [293000]|5356.87||||5356.87|1130.43|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5356.87||||5356.87|2678.44|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5356.87||||5356.87|2142.75|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5356.87||||5356.87|2142.75|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5356.87||||5356.87|2517.73|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5356.87||||5356.87|2196.32|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA [1260]|CIGNA PPO [126025]|5356.87||||5356.87|1985|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5356.87||||5356.87|1712|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5356.87||||5356.87|2678.44|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5356.87||||5356.87|1076.6|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5356.87||||5356.87|2410.59|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5356.87||||5356.87|2410.59|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5356.87||||5356.87|0|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|Self-pay|Self-pay|5356.87||||5356.87|1071.37|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|TML [1980]|TML [198000]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5356.87||||5356.87|353.3|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5356.87||||5356.87|1712|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UNICARE [2040]|UNICARE [204000]|5356.87||||5356.87|1712|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5356.87||||5356.87|1712|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WEB TPA [2115]|WEB TPA [211500]|5356.87||||5356.87|3428.4|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5356.87||||5356.87|940.33|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5356.87||||5356.87|1880.67|3428.4|353.3
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WORKER'S COMP [2125]|TML WC [212537]|5356.87||||5356.87|1712|3428.4|353.3
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AARP [1000]|AARP [100000]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AETNA [1015]|AETNA [101529]|4640.1||||4640.1|2088.05|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AMBETTER [2930]|AMBETTER [293000]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4640.1||||4640.1|2320.05|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4640.1||||4640.1|1856.04|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4640.1||||4640.1|1856.04|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4640.1||||4640.1|2180.85|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4640.1||||4640.1|1902.44|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|CIGNA [1260]|CIGNA PPO [126025]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4640.1||||4640.1|2320.05|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4640.1||||4640.1|2088.05|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4640.1||||4640.1|2088.05|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4640.1||||4640.1|0|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|Self-pay|Self-pay|4640.1||||4640.1|928.02|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|TML [1980]|TML [198000]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4640.1||||4640.1|263.85|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|UNICARE [2040]|UNICARE [204000]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|WEB TPA [2115]|WEB TPA [211500]|4640.1||||4640.1|2969.66|2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4640.1||||4640.1||2969.66|263.85
36045393|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DECOMPRESSION|1|WORKER'S COMP [2125]|TML WC [212537]|4640.1||||4640.1||2969.66|263.85
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AARP [1000]|AARP [100000]|162||||162||162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AETNA [1015]|AETNA [101529]|162||||162|72.9|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AMBETTER [2930]|AMBETTER [293000]|162||||162|52.99|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|162||||162|81|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|162||||162|64.8|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|162||||162|64.8|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|162||||162|76.14|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|162||||162|66.42|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA [1260]|CIGNA PPO [126025]|162||||162|162|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|162||||162||162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|162||||162|81|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162||||162|72.9|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162||||162|72.9|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162||||162|0|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|Self-pay|Self-pay|162||||162|32.4|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|TML [1980]|TML [198000]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|162||||162|22.68|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162||||162||162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UNICARE [2040]|UNICARE [204000]|162||||162||162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162||||162||162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WEB TPA [2115]|WEB TPA [211500]|162||||162|111.78|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162||||162|50.47|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|162||||162|100.94|162|22.68
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WORKER'S COMP [2125]|TML WC [212537]|162||||162||162|22.68
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AARP [1000]|AARP [100000]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AETNA [1015]|AETNA [101529]|17913.55||||17913.55|8061.1|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AMBETTER [2930]|AMBETTER [293000]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17913.55||||17913.55|8956.78|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17913.55||||17913.55|7165.42|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17913.55||||17913.55|7165.42|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17913.55||||17913.55|8419.37|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17913.55||||17913.55|7344.56|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|CIGNA [1260]|CIGNA PPO [126025]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17913.55||||17913.55|8956.78|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17913.55||||17913.55|8061.1|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17913.55||||17913.55|8061.1|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17913.55||||17913.55|0|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|Self-pay|Self-pay|17913.55||||17913.55|3582.71|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|TML [1980]|TML [198000]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17913.55||||17913.55|405.18|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|UNICARE [2040]|UNICARE [204000]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|WEB TPA [2115]|WEB TPA [211500]|17913.55||||17913.55|11464.67|11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17913.55||||17913.55||11464.67|405.18
36062287|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR|1|WORKER'S COMP [2125]|TML WC [212537]|17913.55||||17913.55||11464.67|405.18
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|23.96||||23.96|10.78|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.96||||23.96|11.98|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.96||||23.96|9.58|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.96||||23.96|9.58|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.96||||23.96|11.26|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.96||||23.96|9.82|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|23.96||||23.96|9.58|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.96||||23.96|11.98|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.96||||23.96|10.78|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.96||||23.96|10.78|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|23.96||||23.96|4.79|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.96||||23.96|3.35|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.96||||23.96|0|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|23.96||||23.96|16.53|16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.96||||23.96||16.53|3.35
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|23.96||||23.96|0|16.53|3.35
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.02||||5.02|2.26|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.02||||5.02|2.51|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.02||||5.02|2.01|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.02||||5.02|2.01|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.02||||5.02|2.36|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.02||||5.02|2.06|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.02||||5.02|2.01|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.02||||5.02|2.51|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.02||||5.02|2.26|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.02||||5.02|2.26|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|Self-pay|Self-pay|5.02||||5.02|1|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.02||||5.02|0.7|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.02||||5.02|0|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.02||||5.02|3.46|3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.02||||5.02||3.46|0.7
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.02||||5.02|0|3.46|0.7
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AARP [1000]|AARP [100000]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AETNA [1015]|AETNA [101529]|4619.94||||4619.94|2078.97|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AMBETTER [2930]|AMBETTER [293000]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4619.94||||4619.94|2309.97|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4619.94||||4619.94|1847.98|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4619.94||||4619.94|1847.98|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4619.94||||4619.94|2171.37|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4619.94||||4619.94|1894.18|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|CIGNA [1260]|CIGNA PPO [126025]|4619.94||||4619.94|1847.98|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4619.94||||4619.94|2309.97|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4619.94||||4619.94|2078.97|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4619.94||||4619.94|2078.97|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|Self-pay|Self-pay|4619.94||||4619.94|923.99|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|TML [1980]|TML [198000]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4619.94||||4619.94|646.79|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|UNICARE [2040]|UNICARE [204000]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4619.94||||4619.94|0|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|WEB TPA [2115]|WEB TPA [211500]|4619.94||||4619.94|3187.76|3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4619.94||||4619.94||3187.76|646.79
36576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION|7.6 mL|WORKER'S COMP [2125]|TML WC [212537]|4619.94||||4619.94|0|3187.76|646.79
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0.66|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.47||||1.47|0.74|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|0.59|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.59|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.69|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.47||||1.47|0.6|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.47||||1.47|0.59|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.47||||1.47|0.74|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0.66|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0.66|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.29|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.21|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47|0|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.47||||1.47|1.01|1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.47||||1.47||1.01|0.21
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.47||||1.47|0|1.01|0.21
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|24.44||||24.44|11|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.44||||24.44|12.22|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.44||||24.44|9.78|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.44||||24.44|9.78|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.44||||24.44|11.49|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.44||||24.44|10.02|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|24.44||||24.44|9.78|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.44||||24.44|12.22|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.44||||24.44|11|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.44||||24.44|11|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|24.44||||24.44|4.89|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.44||||24.44|3.42|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.44||||24.44|0|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|24.44||||24.44|16.86|16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.44||||24.44||16.86|3.42
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|24.44||||24.44|0|16.86|3.42
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.81||||8.81|3.96|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.81||||8.81|4.41|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.81||||8.81|3.52|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.81||||8.81|3.52|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.81||||8.81|4.14|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.81||||8.81|3.61|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.81||||8.81|3.52|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.81||||8.81|4.41|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.81||||8.81|3.96|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.81||||8.81|3.96|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|8.81||||8.81|1.76|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.81||||8.81|1.23|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.81||||8.81|0|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.81||||8.81|6.08|6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.81||||8.81||6.08|1.23
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.81||||8.81|0|6.08|1.23
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|172.66||||172.66|77.7|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|172.66||||172.66|86.33|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|172.66||||172.66|69.06|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|172.66||||172.66|69.06|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|172.66||||172.66|81.15|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|172.66||||172.66|70.79|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|172.66||||172.66|69.06|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|172.66||||172.66|86.33|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|172.66||||172.66|77.7|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|172.66||||172.66|77.7|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|172.66||||172.66|34.53|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|172.66||||172.66|24.17|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|172.66||||172.66|0|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|172.66||||172.66|119.14|119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|172.66||||172.66||119.14|24.17
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|172.66||||172.66|0|119.14|24.17
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.57||||2.57|1.16|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.57||||2.57|1.29|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.57||||2.57|1.03|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.57||||2.57|1.03|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.57||||2.57|1.21|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.57||||2.57|1.05|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.57||||2.57|1.03|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.57||||2.57|1.29|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.57||||2.57|1.16|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.57||||2.57|1.16|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.57||||2.57|0.51|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.57||||2.57|0.36|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.57||||2.57|0|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.57||||2.57|1.77|1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.57||||2.57||1.77|0.36
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.57||||2.57|0|1.77|0.36
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|396||||396|178.2|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|396||||396|198|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|158.4|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|158.4|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|186.12|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|396||||396|162.36|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|396||||396|158.4|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|396||||396|198|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|178.2|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|178.2|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|396||||396|79.2|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|55.44|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396|0|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|396||||396|273.24|273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396||273.24|55.44
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|396||||396|0|273.24|55.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.17||||3.17|1.43|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.17||||3.17|1.59|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.17||||3.17|1.27|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.17||||3.17|1.27|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.17||||3.17|1.49|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.17||||3.17|1.3|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.17||||3.17|1.27|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.17||||3.17|1.59|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.17||||3.17|1.43|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.17||||3.17|1.43|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.17||||3.17|0.63|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.17||||3.17|0.44|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.17||||3.17|0|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.17||||3.17|2.19|2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.17||||3.17||2.19|0.44
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.17||||3.17|0|2.19|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.38||||6.38|2.87|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.38||||6.38|3.19|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.38||||6.38|2.55|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.38||||6.38|2.55|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.38||||6.38|3|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.38||||6.38|2.62|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.38||||6.38|2.55|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.38||||6.38|3.19|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.38||||6.38|2.87|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.38||||6.38|2.87|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.38||||6.38|1.28|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.38||||6.38|0.89|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.38||||6.38|0|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.38||||6.38|4.4|4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.38||||6.38||4.4|0.89
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.38||||6.38|0|4.4|0.89
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AARP [1000]|AARP [100000]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AETNA [1015]|AETNA [101529]|34.32||||34.32|15.44|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AMBETTER [2930]|AMBETTER [293000]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34.32||||34.32|17.16|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.32||||34.32|13.73|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.32||||34.32|13.73|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.32||||34.32|16.13|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34.32||||34.32|14.07|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|CIGNA [1260]|CIGNA PPO [126025]|34.32||||34.32|13.73|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|GROUP PENSION ADMIN [1450]|GPA [145000]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34.32||||34.32|17.16|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.32||||34.32|15.44|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.32||||34.32|15.44|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|PHCS [1780]|PHCS MULTIPLAN [178000]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|Self-pay|Self-pay|34.32||||34.32|6.86|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|TML [1980]|TML [198000]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.32||||34.32|4.8|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|UNICARE [2040]|UNICARE [204000]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.32||||34.32|0|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|WEB TPA [2115]|WEB TPA [211500]|34.32||||34.32|23.68|23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.32||||34.32||23.68|4.8
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|20 g|WORKER'S COMP [2125]|TML WC [212537]|34.32||||34.32|0|23.68|4.8
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AARP [1000]|AARP [100000]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AETNA [1015]|AETNA [101529]|27.72||||27.72|12.47|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AMBETTER [2930]|AMBETTER [293000]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.72||||27.72|13.86|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.72||||27.72|11.09|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.72||||27.72|11.09|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.72||||27.72|13.03|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.72||||27.72|11.37|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|CIGNA [1260]|CIGNA PPO [126025]|27.72||||27.72|11.09|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.72||||27.72|13.86|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.72||||27.72|12.47|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.72||||27.72|12.47|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|Self-pay|Self-pay|27.72||||27.72|5.54|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|TML [1980]|TML [198000]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.72||||27.72|3.88|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|UNICARE [2040]|UNICARE [204000]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.72||||27.72|0|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|WEB TPA [2115]|WEB TPA [211500]|27.72||||27.72|19.13|19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.72||||27.72||19.13|3.88
3731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL OINTMENT|28 g|WORKER'S COMP [2125]|TML WC [212537]|27.72||||27.72|0|19.13|3.88
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.78||||3.78|1.7|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.78||||3.78|1.89|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.78||||3.78|1.51|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.78||||3.78|1.51|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.78||||3.78|1.78|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.78||||3.78|1.55|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.78||||3.78|1.51|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.78||||3.78|1.89|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.78||||3.78|1.7|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.78||||3.78|1.7|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.78||||3.78|0.76|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.78||||3.78|0.53|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.78||||3.78|0|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.78||||3.78|2.61|2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.78||||3.78||2.61|0.53
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.78||||3.78|0|2.61|0.53
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|34.32||||34.32|15.44|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34.32||||34.32|17.16|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.32||||34.32|13.73|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.32||||34.32|13.73|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.32||||34.32|16.13|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34.32||||34.32|14.07|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|34.32||||34.32|13.73|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34.32||||34.32|17.16|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.32||||34.32|15.44|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.32||||34.32|15.44|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|34.32||||34.32|6.86|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.32||||34.32|4.8|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.32||||34.32|0|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|34.32||||34.32|23.68|23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.32||||34.32||23.68|4.8
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|34.32||||34.32|0|23.68|4.8
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.21||||2.21|0.99|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.21||||2.21|1.11|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.21||||2.21|0.88|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.21||||2.21|0.88|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.21||||2.21|1.04|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.21||||2.21|0.91|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.21||||2.21|0.88|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.21||||2.21|1.11|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.21||||2.21|0.99|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.21||||2.21|0.99|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|Self-pay|Self-pay|2.21||||2.21|0.44|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.21||||2.21|0.31|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.21||||2.21|0|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.21||||2.21|1.52|1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.21||||2.21||1.52|0.31
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.21||||2.21|0|1.52|0.31
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.64||||0.64|0.29|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.64||||0.64|0.32|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.64||||0.64|0.26|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.64||||0.64|0.26|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.64||||0.64|0.3|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.64||||0.64|0.26|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.64||||0.64|0.26|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.64||||0.64|0.32|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.64||||0.64|0.29|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.64||||0.64|0.29|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.64||||0.64|0.13|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.64||||0.64|0.09|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.64||||0.64|0|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.64||||0.64|0.44|0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.64||||0.64||0.44|0.09
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.64||||0.64|0|0.44|0.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|14.96||||14.96|6.73|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.96||||14.96|7.48|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.96||||14.96|5.98|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.96||||14.96|5.98|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.96||||14.96|7.03|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.96||||14.96|6.13|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.96||||14.96|5.98|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.96||||14.96|7.48|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.96||||14.96|6.73|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.96||||14.96|6.73|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|14.96||||14.96|2.99|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.96||||14.96|2.09|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.96||||14.96|0|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.96||||14.96|10.32|10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.96||||14.96||10.32|2.09
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.96||||14.96|0|10.32|2.09
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|11.03||||11.03|4.96|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.03||||11.03|5.52|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.03||||11.03|4.41|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.03||||11.03|4.41|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.03||||11.03|5.18|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.03||||11.03|4.52|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.03||||11.03|4.41|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.03||||11.03|5.52|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.03||||11.03|4.96|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.03||||11.03|4.96|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|11.03||||11.03|2.21|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.03||||11.03|1.54|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.03||||11.03|0|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.03||||11.03|7.61|7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.03||||11.03||7.61|1.54
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.03||||11.03|0|7.61|1.54
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AARP [1000]|AARP [100000]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|280.64||||280.64|126.29|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|280.64||||280.64|140.32|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.64||||280.64|112.26|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.64||||280.64|112.26|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.64||||280.64|131.9|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|280.64||||280.64|115.06|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|280.64||||280.64|112.26|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|280.64||||280.64|140.32|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.64||||280.64|126.29|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.64||||280.64|126.29|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|Self-pay|Self-pay|280.64||||280.64|56.13|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|TML [1980]|TML [198000]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.64||||280.64|39.29|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.64||||280.64|0|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|280.64||||280.64|193.64|193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.64||||280.64||193.64|39.29
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|280.64||||280.64|0|193.64|39.29
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AARP [1000]|AARP [100000]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|309.54||||309.54|139.29|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|309.54||||309.54|154.77|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|309.54||||309.54|123.82|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|309.54||||309.54|123.82|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|309.54||||309.54|145.48|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|309.54||||309.54|126.91|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|309.54||||309.54|123.82|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|309.54||||309.54|154.77|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|309.54||||309.54|139.29|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|309.54||||309.54|139.29|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|Self-pay|Self-pay|309.54||||309.54|61.91|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|TML [1980]|TML [198000]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|309.54||||309.54|43.34|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|309.54||||309.54|0|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|309.54||||309.54|213.58|213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|309.54||||309.54||213.58|43.34
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|309.54||||309.54|0|213.58|43.34
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.57||||3.57|1.61|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.57||||3.57|1.79|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.57||||3.57|1.43|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.57||||3.57|1.43|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.57||||3.57|1.68|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.57||||3.57|1.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.57||||3.57|1.43|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.57||||3.57|1.79|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.57||||3.57|1.61|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.57||||3.57|1.61|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.57||||3.57|0.71|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.57||||3.57|0.5|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.57||||3.57|0|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.57||||3.57|2.46|2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.57||||3.57||2.46|0.5
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.57||||3.57|0|2.46|0.5
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|1.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.18||||4.18|1.67|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|1.67|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.18||||4.18|1.96|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|1.71|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|1.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|1.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.18||||4.18|0.59|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18|0|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.18||||4.18||2.88|0.59
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18|0|2.88|0.59
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.1||||109.1|54.55|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.1||||109.1|54.55|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109.1||||109.1|51.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109.1||||109.1|51.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.1||||109.1|44.73|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.1||||109.1|44.73|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|109.1||||109.1|43.64|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.1||||109.1|54.55|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.1||||109.1|54.55|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.1||||109.1|49.1|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|109.1||||109.1|21.82|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|109.1||||109.1|21.82|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109.1||||109.1|15.27|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109.1||||109.1|15.27|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|109.1||||109.1|75.28|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109.1||||109.1||75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|109.1||||109.1|0|75.28|15.27
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|109.1||||109.1|0|75.28|15.27
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|75.36||||75.36|33.91|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.36||||75.36|37.68|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.36||||75.36|30.14|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.36||||75.36|30.14|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.36||||75.36|35.42|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.36||||75.36|30.9|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|75.36||||75.36|30.14|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.36||||75.36|37.68|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.36||||75.36|33.91|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.36||||75.36|33.91|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|75.36||||75.36|15.07|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.36||||75.36|10.55|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.36||||75.36|0|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|75.36||||75.36|52|52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.36||||75.36||52|10.55
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|75.36||||75.36|0|52|10.55
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|106.96||||106.96|48.13|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|106.96||||106.96|53.48|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106.96||||106.96|42.78|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106.96||||106.96|42.78|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106.96||||106.96|50.27|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|106.96||||106.96|43.85|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|106.96||||106.96|42.78|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|106.96||||106.96|53.48|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.96||||106.96|48.13|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106.96||||106.96|48.13|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|106.96||||106.96|21.39|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106.96||||106.96|14.97|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106.96||||106.96|0|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|106.96||||106.96|73.8|73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106.96||||106.96||73.8|14.97
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|106.96||||106.96|0|73.8|14.97
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|301.72||||301.72|135.77|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|301.72||||301.72|150.86|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|301.72||||301.72|120.69|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|301.72||||301.72|120.69|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|301.72||||301.72|141.81|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|301.72||||301.72|123.71|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|301.72||||301.72|120.69|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|301.72||||301.72|150.86|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|301.72||||301.72|135.77|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|301.72||||301.72|135.77|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|Self-pay|Self-pay|301.72||||301.72|60.34|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|301.72||||301.72|42.24|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|301.72||||301.72|0|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|301.72||||301.72|208.19|208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|301.72||||301.72||208.19|42.24
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|301.72||||301.72|0|208.19|42.24
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|12.36||||12.36|5.56|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.36||||12.36|6.18|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.36||||12.36|4.94|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.36||||12.36|4.94|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.36||||12.36|5.81|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.36||||12.36|5.07|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.36||||12.36|4.94|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.36||||12.36|6.18|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.36||||12.36|5.56|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.36||||12.36|5.56|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|12.36||||12.36|2.47|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.36||||12.36|1.73|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.36||||12.36|0|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.36||||12.36|8.53|8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.36||||12.36||8.53|1.73
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.36||||12.36|0|8.53|1.73
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|22.21||||22.21|9.99|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.21||||22.21|11.11|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.21||||22.21|8.88|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.21||||22.21|8.88|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.21||||22.21|10.44|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.21||||22.21|9.11|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|22.21||||22.21|8.88|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.21||||22.21|11.11|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.21||||22.21|9.99|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.21||||22.21|9.99|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|22.21||||22.21|4.44|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.21||||22.21|3.11|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.21||||22.21|0|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|22.21||||22.21|15.32|15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.21||||22.21||15.32|3.11
38224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|22.21||||22.21|0|15.32|3.11
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AARP [1000]|AARP [100000]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|497.38||||497.38|223.82|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMBETTER [2930]|AMBETTER [293000]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|497.38||||497.38|248.69|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|497.38||||497.38|198.95|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|497.38||||497.38|198.95|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|497.38||||497.38|233.77|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|497.38||||497.38|203.93|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA [1260]|CIGNA PPO [126025]|497.38||||497.38|198.95|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|497.38||||497.38|248.69|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|497.38||||497.38|223.82|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|497.38||||497.38|223.82|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|Self-pay|Self-pay|497.38||||497.38|99.48|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|TML [1980]|TML [198000]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|497.38||||497.38|69.63|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNICARE [2040]|UNICARE [204000]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|497.38||||497.38|0|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WEB TPA [2115]|WEB TPA [211500]|497.38||||497.38|343.19|343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|497.38||||497.38||343.19|69.63
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WORKER'S COMP [2125]|TML WC [212537]|497.38||||497.38|0|343.19|69.63
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AARP [1000]|AARP [100000]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AETNA [1015]|AETNA [101529]|20.79||||20.79|9.36|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AMBETTER [2930]|AMBETTER [293000]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.79||||20.79|10.4|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.79||||20.79|8.32|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.79||||20.79|8.32|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.79||||20.79|9.77|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.79||||20.79|8.52|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA [1260]|CIGNA PPO [126025]|20.79||||20.79|8.32|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.79||||20.79|10.4|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.79||||20.79|9.36|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.79||||20.79|9.36|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|Self-pay|Self-pay|20.79||||20.79|4.16|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|TML [1980]|TML [198000]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.79||||20.79|2.91|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UNICARE [2040]|UNICARE [204000]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.79||||20.79|0|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WEB TPA [2115]|WEB TPA [211500]|20.79||||20.79|14.35|14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.79||||20.79||14.35|2.91
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WORKER'S COMP [2125]|TML WC [212537]|20.79||||20.79|0|14.35|2.91
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.4|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.89||||0.89|0.45|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.36|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.36|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.42|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.89||||0.89|0.36|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.89||||0.89|0.36|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.89||||0.89|0.45|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.4|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.4|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.18|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.12|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89|0|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.89||||0.89|0.61|0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.12
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.89||||0.89|0|0.61|0.12
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|36.7||||36.7|16.52|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.7||||36.7|18.35|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.7||||36.7|14.68|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.7||||36.7|14.68|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.7||||36.7|17.25|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.7||||36.7|15.05|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|36.7||||36.7|14.68|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.7||||36.7|18.35|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.7||||36.7|16.52|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.7||||36.7|16.52|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|Self-pay|Self-pay|36.7||||36.7|7.34|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|TML [1980]|TML [198000]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.7||||36.7|5.14|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNICARE [2040]|UNICARE [204000]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.7||||36.7|0|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|36.7||||36.7|25.32|25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.7||||36.7||25.32|5.14
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|36.7||||36.7|0|25.32|5.14
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.17||||3.17|1.43|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.17||||3.17|1.59|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.17||||3.17|1.27|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.17||||3.17|1.27|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.17||||3.17|1.49|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.17||||3.17|1.3|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.17||||3.17|1.27|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.17||||3.17|1.59|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.17||||3.17|1.43|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.17||||3.17|1.43|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.17||||3.17|0.63|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.17||||3.17|0.44|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.17||||3.17|0|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.17||||3.17|2.19|2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.17||||3.17||2.19|0.44
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.17||||3.17|0|2.19|0.44
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AARP [1000]|AARP [100000]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AETNA [1015]|AETNA [101529]|601.53||||601.53|270.69|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|601.53||||601.53|300.77|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|601.53||||601.53|240.61|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|601.53||||601.53|240.61|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|601.53||||601.53|282.72|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|601.53||||601.53|246.63|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|601.53||||601.53|240.61|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|601.53||||601.53|300.77|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|601.53||||601.53|270.69|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|601.53||||601.53|270.69|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|Self-pay|Self-pay|601.53||||601.53|120.31|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|TML [1980]|TML [198000]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|601.53||||601.53|84.21|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UNICARE [2040]|UNICARE [204000]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|601.53||||601.53|0|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|601.53||||601.53|415.06|415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|601.53||||601.53||415.06|84.21
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|601.53||||601.53|0|415.06|84.21
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|144.54||||144.54|65.04|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|144.54||||144.54|72.27|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144.54||||144.54|57.82|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144.54||||144.54|57.82|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144.54||||144.54|67.93|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|144.54||||144.54|59.26|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|144.54||||144.54|57.82|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|144.54||||144.54|72.27|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144.54||||144.54|65.04|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144.54||||144.54|65.04|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|144.54||||144.54|28.91|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144.54||||144.54|20.24|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144.54||||144.54|0|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|144.54||||144.54|99.73|99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144.54||||144.54||99.73|20.24
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|144.54||||144.54|0|99.73|20.24
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.98||||8.98|4.04|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.98||||8.98|4.49|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.98||||8.98|3.59|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.98||||8.98|3.59|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.98||||8.98|4.22|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.98||||8.98|3.68|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.98||||8.98|3.59|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.98||||8.98|4.49|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.98||||8.98|4.04|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.98||||8.98|4.04|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.98||||8.98|1.8|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.98||||8.98|1.26|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.98||||8.98|0|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.98||||8.98|6.2|6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.98||||8.98||6.2|1.26
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.98||||8.98|0|6.2|1.26
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AARP [1000]|AARP [100000]|940.32||||940.32|940.32|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA [1015]|AETNA [101529]|940.32||||940.32|423.14|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMBETTER [2930]|AMBETTER [293000]|940.32||||940.32|197.94|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|940.32||||940.32|470.16|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|940.32||||940.32|376.13|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|940.32||||940.32|376.13|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|940.32||||940.32|441.95|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|940.32||||940.32|385.53|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA [1260]|CIGNA PPO [126025]|940.32||||940.32|376.13|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|940.32||||940.32|940.32|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|940.32||||940.32|470.16|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|940.32||||940.32|423.14|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|940.32||||940.32|423.14|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|940.32||||940.32|0|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|Self-pay|Self-pay|940.32||||940.32|188.06|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|TML [1980]|TML [198000]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|940.32||||940.32|131.64|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|940.32||||940.32|940.32|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNICARE [2040]|UNICARE [204000]|940.32||||940.32|940.32|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|940.32||||940.32|940.32|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WEB TPA [2115]|WEB TPA [211500]|940.32||||940.32|648.82|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|940.32||||940.32|188.51|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|940.32||||940.32|377.02|940.32|131.64
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WORKER'S COMP [2125]|TML WC [212537]|940.32||||940.32|940.32|940.32|131.64
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AARP [1000]|AARP [100000]|1412.64||||1412.64|1412.64|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA [1015]|AETNA [101529]|1412.64||||1412.64|635.69|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMBETTER [2930]|AMBETTER [293000]|1412.64||||1412.64|273.57|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1412.64||||1412.64|706.32|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1412.64||||1412.64|565.06|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1412.64||||1412.64|565.06|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1412.64||||1412.64|663.94|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1412.64||||1412.64|579.18|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA [1260]|CIGNA PPO [126025]|1412.64||||1412.64|565.06|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1412.64||||1412.64|1412.64|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1412.64||||1412.64|706.32|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1412.64||||1412.64|635.69|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1412.64||||1412.64|635.69|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1412.64||||1412.64|0|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|Self-pay|Self-pay|1412.64||||1412.64|282.53|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|TML [1980]|TML [198000]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1412.64||||1412.64|153|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1412.64||||1412.64|1412.64|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNICARE [2040]|UNICARE [204000]|1412.64||||1412.64|1412.64|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1412.64||||1412.64|1412.64|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WEB TPA [2115]|WEB TPA [211500]|1412.64||||1412.64|974.72|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1412.64||||1412.64|260.55|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1412.64||||1412.64|521.09|1412.64|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WORKER'S COMP [2125]|TML WC [212537]|1412.64||||1412.64|1412.64|1412.64|153
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AARP [1000]|AARP [100000]|394.56||||394.56|394.56|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA [1015]|AETNA [101529]|394.56||||394.56|177.55|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMBETTER [2930]|AMBETTER [293000]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|394.56||||394.56|197.28|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|394.56||||394.56|157.82|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|394.56||||394.56|157.82|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|394.56||||394.56|185.44|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|394.56||||394.56|161.77|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA [1260]|CIGNA PPO [126025]|394.56||||394.56|157.82|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|394.56||||394.56|394.56|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|394.56||||394.56|197.28|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|394.56||||394.56|177.55|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|394.56||||394.56|177.55|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|394.56||||394.56|0|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|Self-pay|Self-pay|394.56||||394.56|78.91|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|TML [1980]|TML [198000]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|394.56||||394.56|51|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|394.56||||394.56|394.56|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNICARE [2040]|UNICARE [204000]|394.56||||394.56|394.56|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|394.56||||394.56|394.56|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WEB TPA [2115]|WEB TPA [211500]|394.56||||394.56|272.25|394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|394.56||||394.56||394.56|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WORKER'S COMP [2125]|TML WC [212537]|394.56||||394.56|394.56|394.56|51
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.95||||2.95|1.33|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.95||||2.95|1.48|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.95||||2.95|1.18|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.95||||2.95|1.18|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.95||||2.95|1.39|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.95||||2.95|1.21|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.95||||2.95|1.18|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.95||||2.95|1.48|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.95||||2.95|1.33|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.95||||2.95|1.33|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.95||||2.95|0.59|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.95||||2.95|0.41|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.95||||2.95|0|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.95||||2.95|2.04|2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.95||||2.95||2.04|0.41
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.95||||2.95|0|2.04|0.41
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AARP [1000]|AARP [100000]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AETNA [1015]|AETNA [101529]|256.02||||256.02|115.21|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMBETTER [2930]|AMBETTER [293000]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|256.02||||256.02|128.01|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|256.02||||256.02|102.41|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|256.02||||256.02|102.41|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|256.02||||256.02|120.33|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|256.02||||256.02|104.97|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA [1260]|CIGNA PPO [126025]|256.02||||256.02|102.41|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|256.02||||256.02|128.01|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|256.02||||256.02|115.21|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|256.02||||256.02|115.21|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|Self-pay|Self-pay|256.02||||256.02|51.2|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|TML [1980]|TML [198000]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|256.02||||256.02|35.84|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNICARE [2040]|UNICARE [204000]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|256.02||||256.02|0|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WEB TPA [2115]|WEB TPA [211500]|256.02||||256.02|176.65|176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|256.02||||256.02||176.65|35.84
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WORKER'S COMP [2125]|TML WC [212537]|256.02||||256.02|0|176.65|35.84
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AARP [1000]|AARP [100000]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA [1015]|AETNA [101529]|231.75||||231.75|104.29|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMBETTER [2930]|AMBETTER [293000]|231.75||||231.75|378.07|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|231.75||||231.75|115.88|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|231.75||||231.75|92.7|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|231.75||||231.75|92.7|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|231.75||||231.75|108.92|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|231.75||||231.75|95.02|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA [1260]|CIGNA PPO [126025]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|231.75||||231.75|115.88|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|231.75||||231.75|104.29|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|231.75||||231.75|104.29|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|231.75||||231.75|0|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|Self-pay|Self-pay|231.75||||231.75|46.35|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|TML [1980]|TML [198000]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|231.75||||231.75|32.45|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNICARE [2040]|UNICARE [204000]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|231.75||||231.75|231.75|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WEB TPA [2115]|WEB TPA [211500]|231.75||||231.75|159.91|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|231.75||||231.75|360.06|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|231.75||||231.75|720.13|720.13|32.45
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WORKER'S COMP [2125]|TML WC [212537]|231.75||||231.75|231.75|720.13|32.45
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|810.6||||810.6|364.77|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|810.6||||810.6|405.3|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|810.6||||810.6|324.24|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|810.6||||810.6|324.24|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|810.6||||810.6|380.98|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|810.6||||810.6|332.35|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|810.6||||810.6|324.24|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|810.6||||810.6|405.3|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|810.6||||810.6|364.77|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|810.6||||810.6|364.77|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|Self-pay|Self-pay|810.6||||810.6|162.12|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|810.6||||810.6|113.48|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|810.6||||810.6|0|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|810.6||||810.6|559.31|559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|810.6||||810.6||559.31|113.48
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|810.6||||810.6|0|559.31|113.48
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|23.33||||23.33|10.5|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.33||||23.33|11.67|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.33||||23.33|9.33|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.33||||23.33|9.33|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.33||||23.33|10.97|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.33||||23.33|9.57|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|23.33||||23.33|9.33|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.33||||23.33|11.67|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.33||||23.33|10.5|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.33||||23.33|10.5|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|23.33||||23.33|4.67|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|TML [1980]|TML [198000]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.33||||23.33|3.27|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.33||||23.33|0|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|23.33||||23.33|16.1|16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.33||||23.33||16.1|3.27
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|23.33||||23.33|0|16.1|3.27
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|21.12||||21.12|9.5|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.12||||21.12|10.56|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|8.45|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|8.45|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|9.93|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.12||||21.12|8.66|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|21.12||||21.12|8.45|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.12||||21.12|10.56|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|9.5|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|9.5|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|21.12||||21.12|4.22|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|TML [1980]|TML [198000]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|2.96|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12|0|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|21.12||||21.12|14.57|14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12||14.57|2.96
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|21.12||||21.12|0|14.57|2.96
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|89.5||||89.5|40.28|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.5||||89.5|44.75|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.5||||89.5|35.8|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.5||||89.5|35.8|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.5||||89.5|42.07|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|89.5||||89.5|36.7|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|89.5||||89.5|35.8|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.5||||89.5|44.75|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.5||||89.5|40.28|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.5||||89.5|40.28|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|89.5||||89.5|17.9|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.5||||89.5|12.53|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.5||||89.5|0|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|89.5||||89.5|61.76|61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89.5||||89.5||61.76|12.53
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|89.5||||89.5|0|61.76|12.53
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|26.14||||26.14|11.76|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.14||||26.14|13.07|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.14||||26.14|10.46|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.14||||26.14|10.46|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.14||||26.14|12.29|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.14||||26.14|10.72|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|26.14||||26.14|10.46|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.14||||26.14|13.07|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.14||||26.14|11.76|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.14||||26.14|11.76|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|26.14||||26.14|5.23|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.14||||26.14|3.66|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.14||||26.14|0|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|26.14||||26.14|18.04|18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.14||||26.14||18.04|3.66
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|26.14||||26.14|0|18.04|3.66
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|15.51|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|15.51|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|13.53|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|13.53|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|14.85|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|Self-pay|Self-pay|33||||33|6.6|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|Self-pay|Self-pay|33||||33|6.6|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|TML [1980]|TML [198000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|TML [1980]|TML [198000]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|4.62|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|4.62|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNICARE [2040]|UNICARE [204000]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNICARE [2040]|UNICARE [204000]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33||22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|33||||33|0|22.77|4.62
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|33||||33|0|22.77|4.62
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14.52||||14.52|6.53|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.52||||14.52|7.26|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.52||||14.52|5.81|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.52||||14.52|5.81|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.52||||14.52|6.82|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.52||||14.52|5.95|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.52||||14.52|5.81|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.52||||14.52|7.26|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.52||||14.52|6.53|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.52||||14.52|6.53|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|Self-pay|Self-pay|14.52||||14.52|2.9|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.52||||14.52|2.03|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.52||||14.52|0|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.52||||14.52|10.02|10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.52||||14.52||10.02|2.03
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.52||||14.52|0|10.02|2.03
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AARP [1000]|AARP [100000]|905||||905|124.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AETNA [1015]|AETNA [101529]|905||||905|407.25|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AMBETTER [2930]|AMBETTER [293000]|905||||905|103.76|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|905||||905|452.5|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|905||||905|362|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|905||||905|362|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|905||||905|425.35|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|905||||905|371.05|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA [1260]|CIGNA PPO [126025]|905||||905|500.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|905||||905|124.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|905||||905|452.5|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|905||||905|113.13|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|905||||905|407.25|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|905||||905|407.25|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|905||||905|0|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|Self-pay|Self-pay|905||||905|181|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|TML [1980]|TML [198000]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|905||||905|110.94|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|905||||905|124.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UNICARE [2040]|UNICARE [204000]|905||||905|124.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|905||||905|124.15|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WEB TPA [2115]|WEB TPA [211500]|905||||905|624.45|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|905||||905|86.84|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|905||||905|163.38|624.45|86.84
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WORKER'S COMP [2125]|TML WC [212537]|905||||905|124.15|624.45|86.84
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.29||||12.29|5.53|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.29||||12.29|6.15|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.29||||12.29|4.92|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.29||||12.29|4.92|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.29||||12.29|5.78|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.29||||12.29|5.04|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.29||||12.29|4.92|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.29||||12.29|6.15|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.29||||12.29|5.53|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.29||||12.29|5.53|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|Self-pay|Self-pay|12.29||||12.29|2.46|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.29||||12.29|1.72|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.29||||12.29|0|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.29||||12.29|8.48|8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.29||||12.29||8.48|1.72
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.29||||12.29|0|8.48|1.72
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AARP [1000]|AARP [100000]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA [1015]|AETNA [101529]|3509.2||||3509.2|1579.14|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMBETTER [2930]|AMBETTER [293000]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3509.2||||3509.2|1754.6|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3509.2||||3509.2|1403.68|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3509.2||||3509.2|1403.68|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3509.2||||3509.2|1649.32|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3509.2||||3509.2|1438.77|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA PPO [126025]|3509.2||||3509.2|1403.68|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GROUP PENSION ADMIN [1450]|GPA [145000]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3509.2||||3509.2|1754.6|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3509.2||||3509.2|1579.14|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3509.2||||3509.2|1579.14|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|PHCS [1780]|PHCS MULTIPLAN [178000]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|Self-pay|Self-pay|3509.2||||3509.2|701.84|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|TML [1980]|TML [198000]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3509.2||||3509.2|491.29|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNICARE [2040]|UNICARE [204000]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3509.2||||3509.2|0|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WEB TPA [2115]|WEB TPA [211500]|3509.2||||3509.2|2421.35|2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3509.2||||3509.2||2421.35|491.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TML WC [212537]|3509.2||||3509.2|0|2421.35|491.29
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AARP [1000]|AARP [100000]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA [1015]|AETNA [101529]|5450.87||||5450.87|2452.89|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMBETTER [2930]|AMBETTER [293000]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5450.87||||5450.87|2725.44|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5450.87||||5450.87|2180.35|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5450.87||||5450.87|2180.35|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5450.87||||5450.87|2561.91|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5450.87||||5450.87|2234.86|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA PPO [126025]|5450.87||||5450.87|2180.35|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GROUP PENSION ADMIN [1450]|GPA [145000]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5450.87||||5450.87|2725.44|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5450.87||||5450.87|2452.89|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5450.87||||5450.87|2452.89|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|Self-pay|Self-pay|5450.87||||5450.87|1090.17|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|TML [1980]|TML [198000]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5450.87||||5450.87|763.12|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNICARE [2040]|UNICARE [204000]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5450.87||||5450.87|0|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WEB TPA [2115]|WEB TPA [211500]|5450.87||||5450.87|3761.1|3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5450.87||||5450.87||3761.1|763.12
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TML WC [212537]|5450.87||||5450.87|0|3761.1|763.12
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|2.53||||2.53|1.14|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.53||||2.53|1.27|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.53||||2.53|1.01|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.53||||2.53|1.01|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.53||||2.53|1.19|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.53||||2.53|1.04|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.53||||2.53|1.01|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.53||||2.53|1.27|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.53||||2.53|1.14|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.53||||2.53|1.14|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|Self-pay|Self-pay|2.53||||2.53|0.51|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|TML [1980]|TML [198000]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.53||||2.53|0.35|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.53||||2.53|0|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.53||||2.53|1.75|1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.53||||2.53||1.75|0.35
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.53||||2.53|0|1.75|0.35
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AARP [1000]|AARP [100000]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|44.75||||44.75|20.14|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.75||||44.75|22.38|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.75||||44.75|17.9|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.75||||44.75|17.9|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.75||||44.75|21.03|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.75||||44.75|18.35|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|44.75||||44.75|17.9|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.75||||44.75|22.38|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.75||||44.75|20.14|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.75||||44.75|20.14|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|Self-pay|Self-pay|44.75||||44.75|8.95|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|TML [1980]|TML [198000]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.75||||44.75|6.27|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.75||||44.75|0|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|44.75||||44.75|30.88|30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.75||||44.75||30.88|6.27
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|44.75||||44.75|0|30.88|6.27
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AARP [1000]|AARP [100000]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|35.12||||35.12|15.8|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|35.12||||35.12|17.56|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.12||||35.12|14.05|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.12||||35.12|14.05|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.12||||35.12|16.51|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|35.12||||35.12|14.4|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|35.12||||35.12|14.05|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|35.12||||35.12|17.56|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.12||||35.12|15.8|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.12||||35.12|15.8|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|Self-pay|Self-pay|35.12||||35.12|7.02|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|TML [1980]|TML [198000]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.12||||35.12|4.92|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.12||||35.12|0|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|35.12||||35.12|24.23|24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.12||||35.12||24.23|4.92
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|35.12||||35.12|0|24.23|4.92
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AARP [1000]|AARP [100000]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AETNA [1015]|AETNA [101529]|1347.86||||1347.86|606.54|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1347.86||||1347.86|673.93|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1347.86||||1347.86|539.14|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1347.86||||1347.86|539.14|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1347.86||||1347.86|633.49|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1347.86||||1347.86|552.62|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1347.86||||1347.86|539.14|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1347.86||||1347.86|673.93|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1347.86||||1347.86|606.54|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1347.86||||1347.86|606.54|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|Self-pay|Self-pay|1347.86||||1347.86|269.57|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|TML [1980]|TML [198000]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1347.86||||1347.86|188.7|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNICARE [2040]|UNICARE [204000]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1347.86||||1347.86|0|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|1347.86||||1347.86|930.02|930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1347.86||||1347.86||930.02|188.7
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1347.86||||1347.86|0|930.02|188.7
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AARP [1000]|AARP [100000]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA [1015]|AETNA [101529]|178.2||||178.2|80.19|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMBETTER [2930]|AMBETTER [293000]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|178.2||||178.2|89.1|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178.2||||178.2|71.28|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178.2||||178.2|71.28|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178.2||||178.2|83.75|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|178.2||||178.2|73.06|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA [1260]|CIGNA PPO [126025]|178.2||||178.2|71.28|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|178.2||||178.2|89.1|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178.2||||178.2|80.19|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178.2||||178.2|80.19|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|Self-pay|Self-pay|178.2||||178.2|35.64|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|TML [1980]|TML [198000]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178.2||||178.2|24.95|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNICARE [2040]|UNICARE [204000]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178.2||||178.2|0|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WEB TPA [2115]|WEB TPA [211500]|178.2||||178.2|122.96|122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|178.2||||178.2||122.96|24.95
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WORKER'S COMP [2125]|TML WC [212537]|178.2||||178.2|0|122.96|24.95
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AARP [1000]|AARP [100000]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AETNA [1015]|AETNA [101529]|3.06||||3.06|1.38|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.06||||3.06|1.53|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.06||||3.06|1.22|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.06||||3.06|1.22|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.06||||3.06|1.44|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.06||||3.06|1.25|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|3.06||||3.06|1.22|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.06||||3.06|1.53|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.06||||3.06|1.38|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.06||||3.06|1.38|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|Self-pay|Self-pay|3.06||||3.06|0.61|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|TML [1980]|TML [198000]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.06||||3.06|0.43|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNICARE [2040]|UNICARE [204000]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.06||||3.06|0|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|3.06||||3.06|2.11|2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.06||||3.06||2.11|0.43
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|3.06||||3.06|0|2.11|0.43
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AARP [1000]|AARP [100000]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AETNA [1015]|AETNA [101529]|2.64||||2.64|1.19|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.06|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.06|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.24|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|1.08|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|1.19|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|1.19|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|Self-pay|Self-pay|2.64||||2.64|0.53|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|TML [1980]|TML [198000]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|0.37|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64|0|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.64||||2.64||1.82|0.37
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64|0|1.82|0.37
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AARP [1000]|AARP [100000]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AETNA [1015]|AETNA [101529]|184.53||||184.53|83.04|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMBETTER [2930]|AMBETTER [293000]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.53||||184.53|92.27|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184.53||||184.53|73.81|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184.53||||184.53|73.81|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184.53||||184.53|86.73|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.53||||184.53|75.66|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA [1260]|CIGNA PPO [126025]|184.53||||184.53|73.81|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.53||||184.53|92.27|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.53||||184.53|83.04|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.53||||184.53|83.04|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|Self-pay|Self-pay|184.53||||184.53|36.91|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|TML [1980]|TML [198000]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184.53||||184.53|25.83|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNICARE [2040]|UNICARE [204000]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184.53||||184.53|0|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WEB TPA [2115]|WEB TPA [211500]|184.53||||184.53|127.33|127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184.53||||184.53||127.33|25.83
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WORKER'S COMP [2125]|TML WC [212537]|184.53||||184.53|0|127.33|25.83
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AARP [1000]|AARP [100000]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA [1015]|AETNA [101529]|4.56||||4.56|2.05|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMBETTER [2930]|AMBETTER [293000]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.56||||4.56|2.28|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.56||||4.56|1.82|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.56||||4.56|1.82|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.56||||4.56|2.14|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.56||||4.56|1.87|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA PPO [126025]|4.56||||4.56|1.82|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.56||||4.56|2.28|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.56||||4.56|2.05|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.56||||4.56|2.05|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|Self-pay|Self-pay|4.56||||4.56|0.91|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|TML [1980]|TML [198000]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.56||||4.56|0.64|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNICARE [2040]|UNICARE [204000]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.56||||4.56|0|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WEB TPA [2115]|WEB TPA [211500]|4.56||||4.56|3.15|3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.56||||4.56||3.15|0.64
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TML WC [212537]|4.56||||4.56|0|3.15|0.64
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AARP [1000]|AARP [100000]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AETNA [1015]|AETNA [101529]|23.96||||23.96|10.78|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMBETTER [2930]|AMBETTER [293000]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.96||||23.96|11.98|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.96||||23.96|9.58|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.96||||23.96|9.58|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.96||||23.96|11.26|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.96||||23.96|9.82|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA [1260]|CIGNA PPO [126025]|23.96||||23.96|9.58|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.96||||23.96|11.98|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.96||||23.96|10.78|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.96||||23.96|10.78|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|Self-pay|Self-pay|23.96||||23.96|4.79|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|TML [1980]|TML [198000]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.96||||23.96|3.35|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UNICARE [2040]|UNICARE [204000]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.96||||23.96|0|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WEB TPA [2115]|WEB TPA [211500]|23.96||||23.96|16.53|16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.96||||23.96||16.53|3.35
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WORKER'S COMP [2125]|TML WC [212537]|23.96||||23.96|0|16.53|3.35
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AARP [1000]|AARP [100000]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AETNA [1015]|AETNA [101529]|252.65||||252.65|113.69|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMBETTER [2930]|AMBETTER [293000]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|252.65||||252.65|126.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|252.65||||252.65|101.06|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|252.65||||252.65|101.06|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|252.65||||252.65|118.75|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|252.65||||252.65|103.59|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA [1260]|CIGNA PPO [126025]|252.65||||252.65|101.06|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|252.65||||252.65|126.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|252.65||||252.65|113.69|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|252.65||||252.65|113.69|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|Self-pay|Self-pay|252.65||||252.65|50.53|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|TML [1980]|TML [198000]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|252.65||||252.65|35.37|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNICARE [2040]|UNICARE [204000]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|252.65||||252.65|0|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WEB TPA [2115]|WEB TPA [211500]|252.65||||252.65|174.33|174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|252.65||||252.65||174.33|35.37
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WORKER'S COMP [2125]|TML WC [212537]|252.65||||252.65|0|174.33|35.37
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AARP [1000]|AARP [100000]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA [1015]|AETNA [101529]|174.9||||174.9|78.71|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMBETTER [2930]|AMBETTER [293000]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|174.9||||174.9|87.45|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174.9||||174.9|69.96|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174.9||||174.9|69.96|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174.9||||174.9|82.2|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|174.9||||174.9|71.71|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA [1260]|CIGNA PPO [126025]|174.9||||174.9|69.96|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|174.9||||174.9|87.45|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174.9||||174.9|78.71|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174.9||||174.9|78.71|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|Self-pay|Self-pay|174.9||||174.9|34.98|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|TML [1980]|TML [198000]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174.9||||174.9|24.49|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNICARE [2040]|UNICARE [204000]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174.9||||174.9|0|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WEB TPA [2115]|WEB TPA [211500]|174.9||||174.9|120.68|120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174.9||||174.9||120.68|24.49
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WORKER'S COMP [2125]|TML WC [212537]|174.9||||174.9|0|120.68|24.49
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AARP [1000]|AARP [100000]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA [1015]|AETNA [101529]|4.36||||4.36|1.96|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.36||||4.36|2.18|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.36||||4.36|1.74|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.36||||4.36|1.74|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.36||||4.36|2.05|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.36||||4.36|1.79|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.36||||4.36|1.74|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.36||||4.36|2.18|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.36||||4.36|1.96|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.36||||4.36|1.96|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|Self-pay|Self-pay|4.36||||4.36|0.87|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|TML [1980]|TML [198000]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.36||||4.36|0.61|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNICARE [2040]|UNICARE [204000]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.36||||4.36|0|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.36||||4.36|3.01|3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.36||||4.36||3.01|0.61
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.36||||4.36|0|3.01|0.61
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AARP [1000]|AARP [100000]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA [1015]|AETNA [101529]|5.15||||5.15|2.32|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.15||||5.15|2.58|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.15||||5.15|2.06|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.15||||5.15|2.06|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.15||||5.15|2.42|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.15||||5.15|2.11|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.15||||5.15|2.06|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.15||||5.15|2.58|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.15||||5.15|2.32|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.15||||5.15|2.32|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|Self-pay|Self-pay|5.15||||5.15|1.03|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|TML [1980]|TML [198000]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.15||||5.15|0.72|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNICARE [2040]|UNICARE [204000]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.15||||5.15|0|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.15||||5.15|3.55|3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.15||||5.15||3.55|0.72
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.15||||5.15|0|3.55|0.72
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.37||||0.37|0.17|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.37||||0.37|0.19|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.37||||0.37|0.15|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.37||||0.37|0.15|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.37||||0.37|0.17|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.37||||0.37|0.15|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.37||||0.37|0.15|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.37||||0.37|0.19|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.37||||0.37|0.17|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.37||||0.37|0.17|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|Self-pay|Self-pay|0.37||||0.37|0.07|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.37||||0.37|0.05|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.37||||0.37|0|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.37||||0.37|0.26|0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.37||||0.37||0.26|0.05
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.37||||0.37|0|0.26|0.05
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AARP [1000]|AARP [100000]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AETNA [1015]|AETNA [101529]|7.92||||7.92|3.56|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.92||||7.92|3.96|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.92||||7.92|3.17|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.92||||7.92|3.17|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.92||||7.92|3.72|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.92||||7.92|3.25|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.92||||7.92|3.17|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.92||||7.92|3.96|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.92||||7.92|3.56|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.92||||7.92|3.56|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|Self-pay|Self-pay|7.92||||7.92|1.58|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|TML [1980]|TML [198000]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.92||||7.92|1.11|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.92||||7.92|0|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.92||||7.92|5.46|5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.92||||7.92||5.46|1.11
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.92||||7.92|0|5.46|1.11
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AARP [1000]|AARP [100000]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AETNA [1015]|AETNA [101529]|27.72||||27.72|12.47|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AMBETTER [2930]|AMBETTER [293000]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.72||||27.72|13.86|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.72||||27.72|11.09|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.72||||27.72|11.09|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.72||||27.72|13.03|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.72||||27.72|11.37|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|CIGNA [1260]|CIGNA PPO [126025]|27.72||||27.72|11.09|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.72||||27.72|13.86|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.72||||27.72|12.47|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.72||||27.72|12.47|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|Self-pay|Self-pay|27.72||||27.72|5.54|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|TML [1980]|TML [198000]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.72||||27.72|3.88|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|UNICARE [2040]|UNICARE [204000]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.72||||27.72|0|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|WEB TPA [2115]|WEB TPA [211500]|27.72||||27.72|19.13|19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.72||||27.72||19.13|3.88
4083726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM WRAP|28 g|WORKER'S COMP [2125]|TML WC [212537]|27.72||||27.72|0|19.13|3.88
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AARP [1000]|AARP [100000]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AETNA [1015]|AETNA [101529]|25.61||||25.61|11.52|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMBETTER [2930]|AMBETTER [293000]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.61||||25.61|12.81|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.61||||25.61|10.24|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.61||||25.61|10.24|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.61||||25.61|12.04|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.61||||25.61|10.5|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA [1260]|CIGNA PPO [126025]|25.61||||25.61|10.24|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|GROUP PENSION ADMIN [1450]|GPA [145000]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.61||||25.61|12.81|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.61||||25.61|11.52|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.61||||25.61|11.52|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|PHCS [1780]|PHCS MULTIPLAN [178000]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|Self-pay|Self-pay|25.61||||25.61|5.12|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|TML [1980]|TML [198000]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.61||||25.61|3.59|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UNICARE [2040]|UNICARE [204000]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.61||||25.61|0|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WEB TPA [2115]|WEB TPA [211500]|25.61||||25.61|17.67|17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.61||||25.61||17.67|3.59
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WORKER'S COMP [2125]|TML WC [212537]|25.61||||25.61|0|17.67|3.59
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|2803.38||||2803.38|1261.52|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2803.38||||2803.38|1401.69|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2803.38||||2803.38|1121.35|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2803.38||||2803.38|1121.35|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2803.38||||2803.38|1317.59|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2803.38||||2803.38|1149.39|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|2803.38||||2803.38|1121.35|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2803.38||||2803.38|1401.69|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2803.38||||2803.38|1261.52|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2803.38||||2803.38|1261.52|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|2803.38||||2803.38|560.68|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2803.38||||2803.38|392.47|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2803.38||||2803.38|0|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|2803.38||||2803.38|1934.33|1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2803.38||||2803.38||1934.33|392.47
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|2803.38||||2803.38|0|1934.33|392.47
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AARP [1000]|AARP [100000]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AETNA [1015]|AETNA [101529]|27.46||||27.46|12.36|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.46||||27.46|13.73|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.46||||27.46|10.98|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.46||||27.46|10.98|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.46||||27.46|12.91|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.46||||27.46|11.26|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|27.46||||27.46|10.98|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.46||||27.46|13.73|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.46||||27.46|12.36|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.46||||27.46|12.36|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|Self-pay|Self-pay|27.46||||27.46|5.49|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|TML [1980]|TML [198000]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.46||||27.46|3.84|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.46||||27.46|0|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|27.46||||27.46|18.95|18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.46||||27.46||18.95|3.84
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|27.46||||27.46|0|18.95|3.84
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.51||||0.51|0.23|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.51||||0.51|0.26|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.51||||0.51|0.2|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.51||||0.51|0.2|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.51||||0.51|0.24|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.51||||0.51|0.21|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.51||||0.51|0.2|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.51||||0.51|0.26|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.51||||0.51|0.23|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.51||||0.51|0.23|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|Self-pay|Self-pay|0.51||||0.51|0.1|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.51||||0.51|0.07|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.51||||0.51|0|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.51||||0.51|0.35|0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.51||||0.51||0.35|0.07
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.51||||0.51|0|0.35|0.07
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.6||||0.6|0.27|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.6||||0.6|0.3|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.6||||0.6|0.24|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.6||||0.6|0.24|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.6||||0.6|0.28|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.6||||0.6|0.25|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.6||||0.6|0.24|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.6||||0.6|0.3|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.6||||0.6|0.27|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.6||||0.6|0.27|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|Self-pay|Self-pay|0.6||||0.6|0.12|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.6||||0.6|0.08|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.6||||0.6|0|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.6||||0.6|0.41|0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.6||||0.6||0.41|0.08
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.6||||0.6|0|0.41|0.08
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|19.01||||19.01|8.55|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.01||||19.01|9.51|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.01||||19.01|7.6|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.01||||19.01|7.6|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.01||||19.01|8.93|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.01||||19.01|7.79|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|19.01||||19.01|7.6|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.01||||19.01|9.51|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.01||||19.01|8.55|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.01||||19.01|8.55|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|19.01||||19.01|3.8|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.01||||19.01|2.66|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.01||||19.01|0|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|19.01||||19.01|13.12|13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.01||||19.01||13.12|2.66
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|19.01||||19.01|0|13.12|2.66
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AARP [1000]|AARP [100000]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AETNA [1015]|AETNA [101529]|2250.6||||2250.6|1012.77|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMBETTER [2930]|AMBETTER [293000]|2250.6||||2250.6|180.32|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2250.6||||2250.6|1125.3|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2250.6||||2250.6|900.24|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2250.6||||2250.6|900.24|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2250.6||||2250.6|1057.78|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2250.6||||2250.6|922.75|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA [1260]|CIGNA PPO [126025]|2250.6||||2250.6|900.24|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2250.6||||2250.6|1125.3|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2250.6||||2250.6|1012.77|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2250.6||||2250.6|1012.77|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|Self-pay|Self-pay|2250.6||||2250.6|450.12|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|TML [1980]|TML [198000]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2250.6||||2250.6|315.08|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNICARE [2040]|UNICARE [204000]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2250.6||||2250.6|0|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WEB TPA [2115]|WEB TPA [211500]|2250.6||||2250.6|1552.91|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2250.6||||2250.6|171.74|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2250.6||||2250.6|343.47|1552.91|171.74
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WORKER'S COMP [2125]|TML WC [212537]|2250.6||||2250.6|0|1552.91|171.74
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AARP [1000]|AARP [100000]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AETNA [1015]|AETNA [101529]|1107.48||||1107.48|498.37|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMBETTER [2930]|AMBETTER [293000]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1107.48||||1107.48|553.74|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1107.48||||1107.48|442.99|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1107.48||||1107.48|442.99|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1107.48||||1107.48|520.52|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1107.48||||1107.48|454.07|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1107.48||||1107.48|442.99|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1107.48||||1107.48|553.74|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1107.48||||1107.48|498.37|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1107.48||||1107.48|498.37|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|Self-pay|Self-pay|1107.48||||1107.48|221.5|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|TML [1980]|TML [198000]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1107.48||||1107.48|155.05|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNICARE [2040]|UNICARE [204000]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1107.48||||1107.48|0|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WEB TPA [2115]|WEB TPA [211500]|1107.48||||1107.48|764.16|764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1107.48||||1107.48||764.16|155.05
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1107.48||||1107.48|0|764.16|155.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AARP [1000]|AARP [100000]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.33||||0.33|0.15|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.33||||0.33|0.17|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.33||||0.33|0.13|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.33||||0.33|0.13|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.33||||0.33|0.16|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.33||||0.33|0.14|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.33||||0.33|0.13|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.33||||0.33|0.17|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.33||||0.33|0.15|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.33||||0.33|0.15|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|Self-pay|Self-pay|0.33||||0.33|0.07|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|TML [1980]|TML [198000]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.33||||0.33|0.05|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.33||||0.33|0|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.33||||0.33|0.23|0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.33||||0.33||0.23|0.05
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.33||||0.33|0|0.23|0.05
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AARP [1000]|AARP [100000]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AETNA [1015]|AETNA [101529]|1.56||||1.56|0.7|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.56||||1.56|0.78|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.56||||1.56|0.62|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.56||||1.56|0.62|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.56||||1.56|0.73|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.56||||1.56|0.64|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.56||||1.56|0.62|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.56||||1.56|0.78|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.56||||1.56|0.7|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.56||||1.56|0.7|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|Self-pay|Self-pay|1.56||||1.56|0.31|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|TML [1980]|TML [198000]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.56||||1.56|0.22|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNICARE [2040]|UNICARE [204000]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.56||||1.56|0|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.56||||1.56|1.08|1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.56||||1.56||1.08|0.22
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.56||||1.56|0|1.08|0.22
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AARP [1000]|AARP [100000]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AETNA [1015]|AETNA [101529]|34.98||||34.98|15.74|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMBETTER [2930]|AMBETTER [293000]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34.98||||34.98|17.49|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.98||||34.98|13.99|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.98||||34.98|13.99|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.98||||34.98|16.44|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34.98||||34.98|14.34|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|34.98||||34.98|13.99|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34.98||||34.98|17.49|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.98||||34.98|15.74|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.98||||34.98|15.74|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|Self-pay|Self-pay|34.98||||34.98|7|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|TML [1980]|TML [198000]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.98||||34.98|4.9|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNICARE [2040]|UNICARE [204000]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.98||||34.98|0|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WEB TPA [2115]|WEB TPA [211500]|34.98||||34.98|24.14|24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.98||||34.98||24.14|4.9
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|34.98||||34.98|0|24.14|4.9
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|22.84||||22.84|10.28|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMBETTER [2930]|AMBETTER [293000]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.84||||22.84|11.42|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.84||||22.84|9.14|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.84||||22.84|9.14|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.84||||22.84|10.73|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.84||||22.84|9.36|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA PPO [126025]|22.84||||22.84|9.14|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.84||||22.84|11.42|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.84||||22.84|10.28|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.84||||22.84|10.28|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|Self-pay|Self-pay|22.84||||22.84|4.57|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|TML [1980]|TML [198000]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.84||||22.84|3.2|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNICARE [2040]|UNICARE [204000]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.84||||22.84|0|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WEB TPA [2115]|WEB TPA [211500]|22.84||||22.84|15.76|15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.84||||22.84||15.76|3.2
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TML WC [212537]|22.84||||22.84|0|15.76|3.2
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AARP [1000]|AARP [100000]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AETNA [1015]|AETNA [101529]|17.44||||17.44|7.85|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.44||||17.44|8.72|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.44||||17.44|6.98|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.44||||17.44|6.98|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.44||||17.44|8.2|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.44||||17.44|7.15|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|17.44||||17.44|6.98|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.44||||17.44|8.72|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.44||||17.44|7.85|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.44||||17.44|7.85|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|Self-pay|Self-pay|17.44||||17.44|3.49|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|TML [1980]|TML [198000]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.44||||17.44|2.44|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNICARE [2040]|UNICARE [204000]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.44||||17.44|0|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|17.44||||17.44|12.03|12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.44||||17.44||12.03|2.44
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|17.44||||17.44|0|12.03|2.44
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|14.74||||14.74|6.63|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.74||||14.74|7.37|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.74||||14.74|5.9|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.74||||14.74|5.9|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.74||||14.74|6.93|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.74||||14.74|6.04|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.74||||14.74|5.9|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.74||||14.74|7.37|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.74||||14.74|6.63|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.74||||14.74|6.63|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|Self-pay|Self-pay|14.74||||14.74|2.95|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|TML [1980]|TML [198000]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.74||||14.74|2.06|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNICARE [2040]|UNICARE [204000]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.74||||14.74|0|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.74||||14.74|10.17|10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.74||||14.74||10.17|2.06
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.74||||14.74|0|10.17|2.06
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|30||||30|13.5|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|30||||30|15|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30||||30|12|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30||||30|12|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30||||30|14.1|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|30||||30|12.3|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|30||||30|12|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|30||||30|15|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30||||30|13.5|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30||||30|13.5|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|30||||30|6|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30||||30|4.2|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30||||30|0|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|30||||30|20.7|20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30||||30||20.7|4.2
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|30||||30|0|20.7|4.2
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AARP [1000]|AARP [100000]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AETNA [1015]|AETNA [101529]|5.28||||5.28|2.38|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.28||||5.28|2.11|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.28||||5.28|2.11|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.28||||5.28|2.48|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|2.16|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|2.38|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.28||||5.28|2.38|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|Self-pay|Self-pay|5.28||||5.28|1.06|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|TML [1980]|TML [198000]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.28||||5.28|0.74|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNICARE [2040]|UNICARE [204000]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.28||||5.28|0|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.28||||5.28||3.64|0.74
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28|0|3.64|0.74
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AARP [1000]|AARP [100000]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AETNA [1015]|AETNA [101529]|28.32||||28.32|12.74|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMBETTER [2930]|AMBETTER [293000]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.32||||28.32|14.16|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.32||||28.32|11.33|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.32||||28.32|11.33|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.32||||28.32|13.31|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28.32||||28.32|11.61|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA [1260]|CIGNA PPO [126025]|28.32||||28.32|11.33|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.32||||28.32|14.16|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.32||||28.32|12.74|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.32||||28.32|12.74|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|Self-pay|Self-pay|28.32||||28.32|5.66|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|TML [1980]|TML [198000]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.32||||28.32|3.96|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNICARE [2040]|UNICARE [204000]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.32||||28.32|0|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WEB TPA [2115]|WEB TPA [211500]|28.32||||28.32|19.54|19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.32||||28.32||19.54|3.96
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WORKER'S COMP [2125]|TML WC [212537]|28.32||||28.32|0|19.54|3.96
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|272.75|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|122.74|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75|9.66|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|136.38|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|109.1|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|109.1|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|128.19|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|111.83|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|272.75|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|136.38|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|122.74|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|122.74|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|0|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|38.19|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|272.75|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|272.75|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|272.75|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75|9.2|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75|17.7|272.75|9.2
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|272.75|272.75|9.2
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|272.75|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|122.74|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|136.38|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|109.1|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|109.1|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|128.19|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|111.83|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|272.75|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|136.38|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|122.74|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|122.74|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|0|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|38.19|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|272.75|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|272.75|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|272.75|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75||272.75|38.19
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|272.75|272.75|38.19
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AARP [1000]|AARP [100000]|255.75||||255.75|255.75|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AETNA [1015]|AETNA [101529]|255.75||||255.75|115.09|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AMBETTER [2930]|AMBETTER [293000]|255.75||||255.75|33.79|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|255.75||||255.75|127.88|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255.75||||255.75|102.3|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255.75||||255.75|102.3|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255.75||||255.75|120.2|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|255.75||||255.75|104.86|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|CIGNA [1260]|CIGNA PPO [126025]|255.75||||255.75|102.3|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|255.75||||255.75|255.75|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|255.75||||255.75|127.88|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255.75||||255.75|115.09|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255.75||||255.75|115.09|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255.75||||255.75|0|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|Self-pay|Self-pay|255.75||||255.75|51.15|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|TML [1980]|TML [198000]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255.75||||255.75|35.81|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255.75||||255.75|255.75|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|UNICARE [2040]|UNICARE [204000]|255.75||||255.75|255.75|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255.75||||255.75|255.75|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|WEB TPA [2115]|WEB TPA [211500]|255.75||||255.75|176.47|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255.75||||255.75|32.18|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255.75||||255.75|64.35|255.75|32.18
41000239|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY FUNCTION GROUP|1|WORKER'S COMP [2125]|TML WC [212537]|255.75||||255.75|255.75|255.75|32.18
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.53|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.18||||1.18|0.59|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.47|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.47|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.55|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.18||||1.18|0.48|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|1.18||||1.18|0.47|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.18||||1.18|0.59|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.53|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.53|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|1.18||||1.18|0.24|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.17|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18|0|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|1.18||||1.18|0.81|0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.17
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|1.18||||1.18|0|0.81|0.17
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AARP [1000]|AARP [100000]|473||||473|374|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA [1015]|AETNA [101529]|473||||473|212.85|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMBETTER [2930]|AMBETTER [293000]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|473||||473|236.5|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|473||||473|189.2|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|473||||473|189.2|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|473||||473|222.31|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|473||||473|193.93|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA [1260]|CIGNA PPO [126025]|473||||473|189.2|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|473||||473|374|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|473||||473|236.5|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|473||||473|212.85|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|473||||473|212.85|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|473||||473|0|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|Self-pay|Self-pay|473||||473|94.6|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|TML [1980]|TML [198000]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|473||||473|66.22|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|473||||473|374|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNICARE [2040]|UNICARE [204000]|473||||473|374|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|473||||473|374|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WEB TPA [2115]|WEB TPA [211500]|473||||473|326.37|374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|473||||473||374|66.22
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WORKER'S COMP [2125]|TML WC [212537]|473||||473|374|374|66.22
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AARP [1000]|AARP [100000]|398||||398|374|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA [1015]|AETNA [101529]|398||||398|179.1|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMBETTER [2930]|AMBETTER [293000]|398||||398|204.82|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|398||||398|199|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|398||||398|159.2|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|398||||398|159.2|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|398||||398|187.06|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|398||||398|163.18|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA [1260]|CIGNA PPO [126025]|398||||398|159.2|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|398||||398|374|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|398||||398|199|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|398||||398|179.1|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|398||||398|179.1|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|398||||398|0|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|Self-pay|Self-pay|398||||398|79.6|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|TML [1980]|TML [198000]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|398||||398|55.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|398||||398|374|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNICARE [2040]|UNICARE [204000]|398||||398|374|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|398||||398|374|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WEB TPA [2115]|WEB TPA [211500]|398||||398|274.62|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|398||||398|180.72|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|398||||398|361.44|374|55.72
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WORKER'S COMP [2125]|TML WC [212537]|398||||398|374|374|55.72
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AARP [1000]|AARP [100000]|664||||664|374|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA [1015]|AETNA [101529]|664||||664|298.8|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMBETTER [2930]|AMBETTER [293000]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|664||||664|332|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|664||||664|265.6|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|664||||664|265.6|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|664||||664|312.08|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|664||||664|272.24|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA [1260]|CIGNA PPO [126025]|664||||664|265.6|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|664||||664|374|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|664||||664|332|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|664||||664|298.8|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|664||||664|298.8|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|664||||664|0|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|Self-pay|Self-pay|664||||664|132.8|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|TML [1980]|TML [198000]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|664||||664|92.96|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|664||||664|374|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNICARE [2040]|UNICARE [204000]|664||||664|374|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|664||||664|374|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WEB TPA [2115]|WEB TPA [211500]|664||||664|458.16|458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|664||||664||458.16|92.96
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WORKER'S COMP [2125]|TML WC [212537]|664||||664|374|458.16|92.96
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AARP [1000]|AARP [100000]|4162||||4162|374|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA [1015]|AETNA [101529]|4162||||4162|1872.9|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMBETTER [2930]|AMBETTER [293000]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4162||||4162|2081|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4162||||4162|1664.8|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4162||||4162|1664.8|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4162||||4162|1956.14|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4162||||4162|1706.42|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA [1260]|CIGNA PPO [126025]|4162||||4162|1664.8|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4162||||4162|374|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4162||||4162|2081|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4162||||4162|1872.9|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4162||||4162|1872.9|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4162||||4162|0|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|Self-pay|Self-pay|4162||||4162|832.4|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|TML [1980]|TML [198000]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4162||||4162|582.68|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4162||||4162|374|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNICARE [2040]|UNICARE [204000]|4162||||4162|374|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4162||||4162|374|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WEB TPA [2115]|WEB TPA [211500]|4162||||4162|2871.78|2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4162||||4162||2871.78|374
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WORKER'S COMP [2125]|TML WC [212537]|4162||||4162|374|2871.78|374
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AARP [1000]|AARP [100000]|146||||146|146|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA [1015]|AETNA [101529]|146||||146|65.7|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMBETTER [2930]|AMBETTER [293000]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|73|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|58.4|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|58.4|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|68.62|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|59.86|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|58.4|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146|146|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|73|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|65.7|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|65.7|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|0|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|Self-pay|Self-pay|146||||146|29.2|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|TML [1980]|TML [198000]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|20.44|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146|146|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNICARE [2040]|UNICARE [204000]|146||||146|146|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146|146|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146||146|20.44
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146|146|146|20.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AARP [1000]|AARP [100000]|346||||346|346|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA [1015]|AETNA [101529]|346||||346|155.7|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMBETTER [2930]|AMBETTER [293000]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|346||||346|173|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|346||||346|138.4|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|346||||346|138.4|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|346||||346|162.62|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|346||||346|141.86|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA [1260]|CIGNA PPO [126025]|346||||346|138.4|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|346||||346|346|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|346||||346|173|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|346||||346|155.7|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|346||||346|155.7|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|346||||346|0|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|Self-pay|Self-pay|346||||346|69.2|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|TML [1980]|TML [198000]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|346||||346|48.44|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|346||||346|346|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNICARE [2040]|UNICARE [204000]|346||||346|346|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|346||||346|346|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WEB TPA [2115]|WEB TPA [211500]|346||||346|238.74|346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|346||||346||346|48.44
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WORKER'S COMP [2125]|TML WC [212537]|346||||346|346|346|48.44
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|1234.2||||1234.2|555.39|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMBETTER [2930]|AMBETTER [293000]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1234.2||||1234.2|617.1|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1234.2||||1234.2|493.68|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1234.2||||1234.2|493.68|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1234.2||||1234.2|580.07|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1234.2||||1234.2|506.02|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|1234.2||||1234.2|493.68|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1234.2||||1234.2|617.1|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1234.2||||1234.2|555.39|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1234.2||||1234.2|555.39|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|1234.2||||1234.2|246.84|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|TML [1980]|TML [198000]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1234.2||||1234.2|172.79|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNICARE [2040]|UNICARE [204000]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1234.2||||1234.2|0|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WEB TPA [2115]|WEB TPA [211500]|1234.2||||1234.2|851.6|851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1234.2||||1234.2||851.6|172.79
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|1234.2||||1234.2|0|851.6|172.79
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AARP [1000]|AARP [100000]|1959.6||||1959.6|1142|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AETNA [1015]|AETNA [101529]|1959.6||||1959.6|881.82|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMBETTER [2930]|AMBETTER [293000]|1959.6||||1959.6|113.57|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1959.6||||1959.6|979.8|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1959.6||||1959.6|783.84|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1959.6||||1959.6|783.84|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1959.6||||1959.6|921.01|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1959.6||||1959.6|803.44|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA [1260]|CIGNA PPO [126025]|1959.6||||1959.6|783.84|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1959.6||||1959.6|1142|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1959.6||||1959.6|979.8|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1959.6||||1959.6|881.82|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1959.6||||1959.6|881.82|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1959.6||||1959.6|0|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|Self-pay|Self-pay|1959.6||||1959.6|391.92|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|TML [1980]|TML [198000]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1959.6||||1959.6|274.34|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1959.6||||1959.6|1142|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UNICARE [2040]|UNICARE [204000]|1959.6||||1959.6|1142|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1959.6||||1959.6|1142|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WEB TPA [2115]|WEB TPA [211500]|1959.6||||1959.6|1352.12|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1959.6||||1959.6|108.16|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1959.6||||1959.6|216.33|1352.12|108.16
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WORKER'S COMP [2125]|TML WC [212537]|1959.6||||1959.6|1142|1352.12|108.16
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|214.4||||214.4|96.48|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|214.4||||214.4|107.2|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214.4||||214.4|85.76|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214.4||||214.4|85.76|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214.4||||214.4|100.77|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|214.4||||214.4|87.9|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|214.4||||214.4|85.76|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|214.4||||214.4|107.2|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.4||||214.4|96.48|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.4||||214.4|96.48|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|214.4||||214.4|42.88|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214.4||||214.4|30.02|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.4||||214.4|0|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|214.4||||214.4|147.94|147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214.4||||214.4||147.94|30.02
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|214.4||||214.4|0|147.94|30.02
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AARP [1000]|AARP [100000]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA [1015]|AETNA [101529]|12.02||||12.02|5.41|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMBETTER [2930]|AMBETTER [293000]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.02||||12.02|6.01|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.02||||12.02|4.81|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.02||||12.02|4.81|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.02||||12.02|5.65|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.02||||12.02|4.93|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA [1260]|CIGNA PPO [126025]|12.02||||12.02|4.81|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.02||||12.02|6.01|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.02||||12.02|5.41|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.02||||12.02|5.41|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|Self-pay|Self-pay|12.02||||12.02|2.4|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|TML [1980]|TML [198000]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.02||||12.02|1.68|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNICARE [2040]|UNICARE [204000]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WEB TPA [2115]|WEB TPA [211500]|12.02||||12.02|8.29|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.02||||12.02||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WORKER'S COMP [2125]|TML WC [212537]|12.02||||12.02|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AARP [1000]|AARP [100000]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA [1015]|AETNA [101529]|16.64||||16.64|7.49|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMBETTER [2930]|AMBETTER [293000]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.64||||16.64|8.32|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.64||||16.64|6.66|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.64||||16.64|6.66|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.64||||16.64|7.82|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.64||||16.64|6.82|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA [1260]|CIGNA PPO [126025]|16.64||||16.64|6.66|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.64||||16.64|8.32|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.64||||16.64|7.49|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.64||||16.64|7.49|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|Self-pay|Self-pay|16.64||||16.64|3.33|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|TML [1980]|TML [198000]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.64||||16.64|2.33|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNICARE [2040]|UNICARE [204000]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.64||||16.64|0|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WEB TPA [2115]|WEB TPA [211500]|16.64||||16.64|11.48|11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.64||||16.64||11.48|1.68
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WORKER'S COMP [2125]|TML WC [212537]|16.64||||16.64|0|11.48|1.68
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|13.2||||13.2|5.94|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|5.28|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|5.28|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.2|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|5.41|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|5.94|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|5.94|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|Self-pay|Self-pay|13.2||||13.2|2.64|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|1.85|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2|0|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.2||||13.2||9.11|1.85
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2|0|9.11|1.85
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|692.79||||692.79|311.76|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|692.79||||692.79|346.4|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|692.79||||692.79|277.12|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|692.79||||692.79|277.12|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|692.79||||692.79|325.61|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|692.79||||692.79|284.04|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|692.79||||692.79|277.12|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|692.79||||692.79|346.4|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|692.79||||692.79|311.76|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|692.79||||692.79|311.76|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|Self-pay|Self-pay|692.79||||692.79|138.56|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|692.79||||692.79|96.99|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|692.79||||692.79|0|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|692.79||||692.79|478.03|478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|692.79||||692.79||478.03|96.99
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|692.79||||692.79|0|478.03|96.99
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AARP [1000]|AARP [100000]|116.75||||116.75|116.75|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA [1015]|AETNA [101529]|116.75||||116.75|22.11|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMBETTER [2930]|AMBETTER [293000]|116.75||||116.75||116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|116.75||||116.75|58.38|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.75||||116.75|46.7|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.75||||116.75|46.7|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.75||||116.75|54.87|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|116.75||||116.75|47.87|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA PPO [126025]|116.75||||116.75|46.7|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|116.75||||116.75|116.75|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|116.75||||116.75|58.38|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.75||||116.75|22.11|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.75||||116.75|22.11|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.75||||116.75|0|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|Self-pay|Self-pay|116.75||||116.75|23.35|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|TML [1980]|TML [198000]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.75||||116.75|16.35|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.75||||116.75|116.75|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNICARE [2040]|UNICARE [204000]|116.75||||116.75|116.75|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.75||||116.75|116.75|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WEB TPA [2115]|WEB TPA [211500]|116.75||||116.75|80.56|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.75||||116.75|12.63|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.75||||116.75|25.64|116.75|12.63
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TML WC [212537]|116.75||||116.75|116.75|116.75|12.63
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AARP [1000]|AARP [100000]|408.75||||408.75|191|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AETNA [1015]|AETNA [101529]|408.75||||408.75|183.94|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AMBETTER [2930]|AMBETTER [293000]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408.75||||408.75|204.38|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.75||||408.75|163.5|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.75||||408.75|163.5|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.75||||408.75|192.11|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408.75||||408.75|167.59|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA [1260]|CIGNA PPO [126025]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408.75||||408.75|191|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408.75||||408.75|204.38|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.75||||408.75|183.94|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.75||||408.75|183.94|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.75||||408.75|0|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|Self-pay|Self-pay|408.75||||408.75|81.75|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|TML [1980]|TML [198000]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.75||||408.75|57.23|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.75||||408.75|191|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UNICARE [2040]|UNICARE [204000]|408.75||||408.75|191|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.75||||408.75|191|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WEB TPA [2115]|WEB TPA [211500]|408.75||||408.75|282.04|282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.75||||408.75||282.04|57.23
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WORKER'S COMP [2125]|TML WC [212537]|408.75||||408.75|191|282.04|57.23
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AARP [1000]|AARP [100000]|292.5||||292.5|191|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AETNA [1015]|AETNA [101529]|292.5||||292.5|131.63|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMBETTER [2930]|AMBETTER [293000]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|292.5||||292.5|146.25|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|292.5||||292.5|117|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|292.5||||292.5|117|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|292.5||||292.5|137.48|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|292.5||||292.5|119.93|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA [1260]|CIGNA PPO [126025]|292.5||||292.5|117|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|292.5||||292.5|191|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|292.5||||292.5|146.25|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|292.5||||292.5|131.63|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|292.5||||292.5|131.63|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|292.5||||292.5|0|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|Self-pay|Self-pay|292.5||||292.5|58.5|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|TML [1980]|TML [198000]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|292.5||||292.5|40.95|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|292.5||||292.5|191|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UNICARE [2040]|UNICARE [204000]|292.5||||292.5|191|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|292.5||||292.5|191|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WEB TPA [2115]|WEB TPA [211500]|292.5||||292.5|201.83|201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|292.5||||292.5||201.83|40.95
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WORKER'S COMP [2125]|TML WC [212537]|292.5||||292.5|191|201.83|40.95
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AARP [1000]|AARP [100000]|204.5||||204.5|191|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AETNA [1015]|AETNA [101529]|204.5||||204.5|92.03|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AMBETTER [2930]|AMBETTER [293000]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|204.5||||204.5|102.25|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204.5||||204.5|81.8|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204.5||||204.5|81.8|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204.5||||204.5|96.12|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|204.5||||204.5|83.85|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA [1260]|CIGNA PPO [126025]|204.5||||204.5|81.8|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|204.5||||204.5|191|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|204.5||||204.5|102.25|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204.5||||204.5|92.03|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204.5||||204.5|92.03|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204.5||||204.5|0|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|Self-pay|Self-pay|204.5||||204.5|40.9|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|TML [1980]|TML [198000]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204.5||||204.5|28.63|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204.5||||204.5|191|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UNICARE [2040]|UNICARE [204000]|204.5||||204.5|191|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204.5||||204.5|191|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WEB TPA [2115]|WEB TPA [211500]|204.5||||204.5|141.11|191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204.5||||204.5||191|28.63
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WORKER'S COMP [2125]|TML WC [212537]|204.5||||204.5|191|191|28.63
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AARP [1000]|AARP [100000]|187.2||||187.2|187.2|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA [1015]|AETNA [101529]|187.2||||187.2|23.18|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMBETTER [2930]|AMBETTER [293000]|187.2||||187.2|15.32|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|187.2||||187.2|93.6|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|187.2||||187.2|74.88|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|187.2||||187.2|74.88|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|187.2||||187.2|87.98|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|187.2||||187.2|76.75|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA [1260]|CIGNA PPO [126025]|187.2||||187.2|74.88|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|187.2||||187.2|187.2|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|187.2||||187.2|93.6|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|187.2||||187.2|23.18|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|187.2||||187.2|23.18|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|187.2||||187.2|0|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|Self-pay|Self-pay|187.2||||187.2|37.44|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|TML [1980]|TML [198000]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|187.2||||187.2|26.21|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|187.2||||187.2|187.2|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNICARE [2040]|UNICARE [204000]|187.2||||187.2|187.2|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|187.2||||187.2|187.2|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WEB TPA [2115]|WEB TPA [211500]|187.2||||187.2|129.17|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|187.2||||187.2|14.45|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|187.2||||187.2|29.18|187.2|14.45
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WORKER'S COMP [2125]|TML WC [212537]|187.2||||187.2|187.2|187.2|14.45
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AARP [1000]|AARP [100000]|233.7||||233.7|191|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AETNA [1015]|AETNA [101529]|233.7||||233.7|18.84|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|233.7||||233.7|116.85|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|233.7||||233.7|93.48|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|233.7||||233.7|93.48|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|233.7||||233.7|109.84|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|233.7||||233.7|95.82|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|233.7||||233.7|93.48|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|233.7||||233.7|191|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|233.7||||233.7|116.85|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|233.7||||233.7|18.84|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|233.7||||233.7|18.84|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|233.7||||233.7|0|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|Self-pay|Self-pay|233.7||||233.7|46.74|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|TML [1980]|TML [198000]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|233.7||||233.7|32.72|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|233.7||||233.7|191|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UNICARE [2040]|UNICARE [204000]|233.7||||233.7|191|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|233.7||||233.7|191|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|233.7||||233.7|161.25|191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|233.7||||233.7||191|18.84
42097016|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|233.7||||233.7|191|191|18.84
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AARP [1000]|AARP [100000]|303.75||||303.75|191|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA [1015]|AETNA [101529]|303.75||||303.75|9.05|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMBETTER [2930]|AMBETTER [293000]|303.75||||303.75|5.91|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.75||||303.75|151.88|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.75||||303.75|121.5|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.75||||303.75|121.5|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.75||||303.75|142.76|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.75||||303.75|124.54|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA PPO [126025]|303.75||||303.75|121.5|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.75||||303.75|191|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.75||||303.75|151.88|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.75||||303.75|9.05|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.75||||303.75|9.05|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.75||||303.75|0|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|Self-pay|Self-pay|303.75||||303.75|60.75|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|TML [1980]|TML [198000]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.75||||303.75|42.53|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.75||||303.75|191|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNICARE [2040]|UNICARE [204000]|303.75||||303.75|191|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.75||||303.75|191|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WEB TPA [2115]|WEB TPA [211500]|303.75||||303.75|209.59|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.75||||303.75|5.63|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.75||||303.75|11.26|209.59|5.63
42097018|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TML WC [212537]|303.75||||303.75|191|209.59|5.63
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AARP [1000]|AARP [100000]|194.5||||194.5|191|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA [1015]|AETNA [101529]|194.5||||194.5|27.57|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMBETTER [2930]|AMBETTER [293000]|194.5||||194.5|18.34|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|194.5||||194.5|97.25|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194.5||||194.5|77.8|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194.5||||194.5|77.8|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194.5||||194.5|91.42|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|194.5||||194.5|79.75|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA PPO [126025]|194.5||||194.5|77.8|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|194.5||||194.5|191|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|194.5||||194.5|97.25|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194.5||||194.5|27.57|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194.5||||194.5|27.57|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194.5||||194.5|0|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|Self-pay|Self-pay|194.5||||194.5|38.9|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|TML [1980]|TML [198000]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194.5||||194.5|27.23|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194.5||||194.5|191|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNICARE [2040]|UNICARE [204000]|194.5||||194.5|191|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194.5||||194.5|191|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WEB TPA [2115]|WEB TPA [211500]|194.5||||194.5|134.21|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194.5||||194.5|16.97|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194.5||||194.5|34.94|191|16.97
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TML WC [212537]|194.5||||194.5|191|191|16.97
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AARP [1000]|AARP [100000]|545.25||||545.25|191|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA [1015]|AETNA [101529]|545.25||||545.25|22.64|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|545.25||||545.25|15.32|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.25||||545.25|272.63|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.25||||545.25|218.1|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.25||||545.25|218.1|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.25||||545.25|256.27|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.25||||545.25|223.55|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|545.25||||545.25|218.1|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.25||||545.25|191|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.25||||545.25|272.63|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.25||||545.25|22.64|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.25||||545.25|22.64|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.25||||545.25|0|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|Self-pay|Self-pay|545.25||||545.25|109.05|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|TML [1980]|TML [198000]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.25||||545.25|76.34|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.25||||545.25|191|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNICARE [2040]|UNICARE [204000]|545.25||||545.25|191|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.25||||545.25|191|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|545.25||||545.25|376.22|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.25||||545.25|14.45|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.25||||545.25|29.18|376.22|14.45
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|545.25||||545.25|191|376.22|14.45
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AARP [1000]|AARP [100000]|210.6||||210.6|191|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA [1015]|AETNA [101529]|210.6||||210.6|31.9|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210.6||||210.6|105.3|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210.6||||210.6|84.24|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210.6||||210.6|84.24|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210.6||||210.6|98.98|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210.6||||210.6|86.35|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|210.6||||210.6|84.24|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210.6||||210.6|191|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210.6||||210.6|105.3|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210.6||||210.6|31.9|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210.6||||210.6|31.9|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210.6||||210.6|0|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|Self-pay|Self-pay|210.6||||210.6|42.12|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|TML [1980]|TML [198000]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210.6||||210.6|29.48|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210.6||||210.6|191|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|210.6||||210.6|191|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210.6||||210.6|191|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|210.6||||210.6|145.31|191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210.6||||210.6||191|29.48
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|210.6||||210.6|191|191|29.48
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AARP [1000]|AARP [100000]|210.6||||210.6|191|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AETNA [1015]|AETNA [101529]|210.6||||210.6|23.21|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210.6||||210.6|105.3|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210.6||||210.6|84.24|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210.6||||210.6|84.24|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210.6||||210.6|98.98|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210.6||||210.6|86.35|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|210.6||||210.6|84.24|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210.6||||210.6|191|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210.6||||210.6|105.3|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210.6||||210.6|23.21|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210.6||||210.6|23.21|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210.6||||210.6|0|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|Self-pay|Self-pay|210.6||||210.6|42.12|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|TML [1980]|TML [198000]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210.6||||210.6|29.48|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210.6||||210.6|191|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UNICARE [2040]|UNICARE [204000]|210.6||||210.6|191|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210.6||||210.6|191|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|210.6||||210.6|145.31|191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210.6||||210.6||191|23.21
42097034|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|210.6||||210.6|191|191|23.21
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|163.2||||163.2|163.2|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|163.2||||163.2|22.11|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|163.2||||163.2|14.91|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|163.2||||163.2|81.6|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163.2||||163.2|65.28|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163.2||||163.2|65.28|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163.2||||163.2|76.7|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|163.2||||163.2|66.91|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|163.2||||163.2|65.28|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|163.2||||163.2|163.2|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|163.2||||163.2|81.6|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163.2||||163.2|22.11|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163.2||||163.2|22.11|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163.2||||163.2|0|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|Self-pay|Self-pay|163.2||||163.2|32.64|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|TML [1980]|TML [198000]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163.2||||163.2|22.85|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163.2||||163.2|163.2|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|163.2||||163.2|163.2|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163.2||||163.2|163.2|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|163.2||||163.2|112.61|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163.2||||163.2|13.99|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163.2||||163.2|28.4|163.2|13.99
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|163.2||||163.2|163.2|163.2|13.99
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|205||||205|191|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|205||||205|46.92|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|205||||205|30.91|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205||||205|102.5|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205||||205|82|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205||||205|82|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205||||205|96.35|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205||||205|84.05|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|205||||205|82|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205||||205|191|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205||||205|102.5|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205||||205|46.92|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205||||205|46.92|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205||||205|0|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|205||||205|41|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TML [1980]|TML [198000]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205||||205|28.7|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205||||205|191|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|205||||205|191|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205||||205|191|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|205||||205|141.45|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205||||205|29.02|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205||||205|58.88|191|28.7
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|205||||205|191|191|28.7
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|246.25||||246.25|191|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|246.25||||246.25|54.01|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|246.25||||246.25|35.89|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|246.25||||246.25|123.13|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246.25||||246.25|98.5|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246.25||||246.25|98.5|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246.25||||246.25|115.74|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|246.25||||246.25|100.96|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|246.25||||246.25|98.5|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|246.25||||246.25|191|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|246.25||||246.25|123.13|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246.25||||246.25|54.01|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246.25||||246.25|54.01|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246.25||||246.25|0|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|246.25||||246.25|49.25|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TML [1980]|TML [198000]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246.25||||246.25|34.48|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246.25||||246.25|191|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNICARE [2040]|UNICARE [204000]|246.25||||246.25|191|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246.25||||246.25|191|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|246.25||||246.25|169.91|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246.25||||246.25|33.58|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246.25||||246.25|68.36|191|33.58
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|246.25||||246.25|191|191|33.58
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AARP [1000]|AARP [100000]|400.68||||400.68|191|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|59.44|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|39.01|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|160.27|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|160.27|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|188.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|164.28|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|191|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|59.44|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|59.44|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|0|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|Self-pay|Self-pay|400.68||||400.68|80.14|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|56.1|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|191|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|191|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|191|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|36.32|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|74.3|276.47|36.32
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|191|276.47|36.32
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AARP [1000]|AARP [100000]|327.3||||327.3|191|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA [1015]|AETNA [101529]|327.3||||327.3|46.38|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|327.3||||327.3|30.91|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|327.3||||327.3|163.65|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327.3||||327.3|130.92|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327.3||||327.3|130.92|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327.3||||327.3|153.83|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|327.3||||327.3|134.19|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|327.3||||327.3|130.92|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|327.3||||327.3|191|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|327.3||||327.3|163.65|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327.3||||327.3|46.38|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327.3||||327.3|46.38|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327.3||||327.3|0|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|Self-pay|Self-pay|327.3||||327.3|65.46|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|TML [1980]|TML [198000]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327.3||||327.3|45.82|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327.3||||327.3|191|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNICARE [2040]|UNICARE [204000]|327.3||||327.3|191|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327.3||||327.3|191|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|327.3||||327.3|225.84|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327.3||||327.3|29.02|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327.3||||327.3|58.88|225.84|29.02
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|327.3||||327.3|191|225.84|29.02
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|191|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|44.96|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|30.18|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|160.27|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|160.27|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|188.32|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|164.28|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|191|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|44.96|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|44.96|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|0|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|56.1|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|191|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|191|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|191|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|27.94|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|57.48|276.47|27.94
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|191|276.47|27.94
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AARP [1000]|AARP [100000]|203||||203|191|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA [1015]|AETNA [101529]|203||||203|36.03|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|203||||203|23.99|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203||||203|101.5|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|81.2|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|81.2|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|95.41|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203||||203|83.23|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|203||||203|81.2|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203||||203|191|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203||||203|101.5|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|36.03|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|36.03|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|0|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|Self-pay|Self-pay|203||||203|40.6|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|TML [1980]|TML [198000]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|28.42|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|191|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|203||||203|191|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|191|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|203||||203|140.07|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|22.85|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|45.9|191|22.85
42097129|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|203||||203|191|191|22.85
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AARP [1000]|AARP [100000]|203||||203|191|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA [1015]|AETNA [101529]|203||||203|34.96|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|203||||203|22.91|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203||||203|101.5|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|81.2|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|81.2|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|95.41|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203||||203|83.23|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|203||||203|81.2|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203||||203|191|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203||||203|101.5|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|34.96|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|34.96|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|0|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|Self-pay|Self-pay|203||||203|40.6|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|TML [1980]|TML [198000]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|28.42|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|191|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|203||||203|191|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|191|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|203||||203|140.07|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|21.82|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|43.88|191|21.82
42097130|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|203||||203|191|191|21.82
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|180||||180|180|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|180||||180|43.12|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|180||||180|28.42|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|180||||180|90|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180||||180|72|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180||||180|72|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180||||180|84.6|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|180||||180|73.8|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|180||||180|72|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|180||||180|180|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|180||||180|90|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180||||180|43.12|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180||||180|43.12|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180||||180|0|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|180||||180|36|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TML [1980]|TML [198000]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180||||180|25.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180||||180|180|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|180||||180|180|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180||||180|180|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|180||||180|124.2|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180||||180|26.76|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180||||180|54.14|180|25.2
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|180||||180|180|180|25.2
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AARP [1000]|AARP [100000]|214||||214|191|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA [1015]|AETNA [101529]|214||||214|28.08|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMBETTER [2930]|AMBETTER [293000]|214||||214|18.53|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|214||||214|107|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|85.6|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|85.6|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|100.58|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|214||||214|87.74|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA PPO [126025]|214||||214|85.6|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|214||||214|191|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|214||||214|107|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|28.08|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|28.08|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|0|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|Self-pay|Self-pay|214||||214|42.8|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|TML [1980]|TML [198000]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|29.96|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214|191|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNICARE [2040]|UNICARE [204000]|214||||214|191|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214|191|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WEB TPA [2115]|WEB TPA [211500]|214||||214|147.66|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214|17.4|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214|35.3|191|17.4
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TML WC [212537]|214||||214|191|191|17.4
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|280.8||||280.8|191|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|280.8||||280.8|60.54|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|280.8||||280.8|39.99|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|280.8||||280.8|140.4|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.8||||280.8|112.32|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.8||||280.8|112.32|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.8||||280.8|131.98|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|280.8||||280.8|115.13|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|280.8||||280.8|112.32|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|280.8||||280.8|191|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|280.8||||280.8|140.4|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.8||||280.8|60.54|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.8||||280.8|60.54|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.8||||280.8|0|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|280.8||||280.8|56.16|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TML [1980]|TML [198000]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.8||||280.8|39.31|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.8||||280.8|191|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|280.8||||280.8|191|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.8||||280.8|191|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|280.8||||280.8|193.75|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.8||||280.8|37.11|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.8||||280.8|76.18|193.75|37.11
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|280.8||||280.8|191|193.75|37.11
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AARP [1000]|AARP [100000]|216.5||||216.5|191|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA [1015]|AETNA [101529]|216.5||||216.5|79.59|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.5||||216.5|108.25|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.5||||216.5|86.6|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.5||||216.5|86.6|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.5||||216.5|101.76|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.5||||216.5|88.77|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|216.5||||216.5|86.6|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.5||||216.5|191|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.5||||216.5|108.25|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.5||||216.5|79.59|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.5||||216.5|79.59|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.5||||216.5|0|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|Self-pay|Self-pay|216.5||||216.5|43.3|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|TML [1980]|TML [198000]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.5||||216.5|30.31|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.5||||216.5|191|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNICARE [2040]|UNICARE [204000]|216.5||||216.5|191|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.5||||216.5|191|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|216.5||||216.5|149.39|191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216.5||||216.5||191|30.31
42097533|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|216.5||||216.5|191|191|30.31
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|191|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|52.38|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|34.41|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|160.27|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|160.27|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|188.32|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|164.28|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|191|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|52.38|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|52.38|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|0|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|56.1|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|191|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|191|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|191|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|32.15|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|65.54|276.47|32.15
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|191|276.47|32.15
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AARP [1000]|AARP [100000]|259.25||||259.25|191|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA [1015]|AETNA [101529]|259.25||||259.25|50.18|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|259.25||||259.25|129.63|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259.25||||259.25|103.7|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259.25||||259.25|103.7|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259.25||||259.25|121.85|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|259.25||||259.25|106.29|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|259.25||||259.25|103.7|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|259.25||||259.25|191|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|259.25||||259.25|129.63|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259.25||||259.25|50.18|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259.25||||259.25|50.18|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259.25||||259.25|0|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|Self-pay|Self-pay|259.25||||259.25|51.85|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|TML [1980]|TML [198000]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259.25||||259.25|36.3|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259.25||||259.25|191|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNICARE [2040]|UNICARE [204000]|259.25||||259.25|191|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259.25||||259.25|191|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|259.25||||259.25|178.88|191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259.25||||259.25||191|36.3
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|259.25||||259.25|191|191|36.3
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AARP [1000]|AARP [100000]|175.5||||175.5|175.5|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA [1015]|AETNA [101529]|175.5||||175.5|50.75|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|175.5||||175.5|87.75|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175.5||||175.5|70.2|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175.5||||175.5|70.2|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175.5||||175.5|82.49|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|175.5||||175.5|71.96|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|175.5||||175.5|70.2|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|175.5||||175.5|175.5|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|175.5||||175.5|87.75|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175.5||||175.5|50.75|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175.5||||175.5|50.75|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175.5||||175.5|0|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|Self-pay|Self-pay|175.5||||175.5|35.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|TML [1980]|TML [198000]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175.5||||175.5|24.57|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175.5||||175.5|175.5|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|175.5||||175.5|175.5|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175.5||||175.5|175.5|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|175.5||||175.5|121.1|175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175.5||||175.5||175.5|24.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|175.5||||175.5|175.5|175.5|24.57
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AARP [1000]|AARP [100000]|607.8||||607.8|191|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA [1015]|AETNA [101529]|607.8||||607.8|248.42|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMBETTER [2930]|AMBETTER [293000]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|607.8||||607.8|303.9|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|607.8||||607.8|243.12|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|607.8||||607.8|243.12|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|607.8||||607.8|285.67|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|607.8||||607.8|249.2|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA [1260]|CIGNA PPO [126025]|607.8||||607.8|243.12|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|607.8||||607.8|191|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|607.8||||607.8|303.9|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|607.8||||607.8|248.42|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|607.8||||607.8|248.42|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|607.8||||607.8|0|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|Self-pay|Self-pay|607.8||||607.8|121.56|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|TML [1980]|TML [198000]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|607.8||||607.8|85.09|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|607.8||||607.8|191|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNICARE [2040]|UNICARE [204000]|607.8||||607.8|191|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|607.8||||607.8|191|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WEB TPA [2115]|WEB TPA [211500]|607.8||||607.8|419.38|419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|607.8||||607.8||419.38|85.09
42097545|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WORKER'S COMP [2125]|TML WC [212537]|607.8||||607.8|191|419.38|85.09
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AARP [1000]|AARP [100000]|303.9||||303.9|191|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA [1015]|AETNA [101529]|303.9||||303.9|99.3|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMBETTER [2930]|AMBETTER [293000]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.9||||303.9|151.95|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.9||||303.9|121.56|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.9||||303.9|121.56|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.9||||303.9|142.83|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.9||||303.9|124.6|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA [1260]|CIGNA PPO [126025]|303.9||||303.9|121.56|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.9||||303.9|191|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.9||||303.9|151.95|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.9||||303.9|99.3|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.9||||303.9|99.3|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.9||||303.9|0|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|Self-pay|Self-pay|303.9||||303.9|60.78|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|TML [1980]|TML [198000]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.9||||303.9|42.55|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.9||||303.9|191|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNICARE [2040]|UNICARE [204000]|303.9||||303.9|191|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.9||||303.9|191|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WEB TPA [2115]|WEB TPA [211500]|303.9||||303.9|209.69|209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.9||||303.9||209.69|42.55
42097546|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WORKER'S COMP [2125]|TML WC [212537]|303.9||||303.9|191|209.69|42.55
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|191|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|122.74|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75|35.11|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|136.38|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|109.1|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|109.1|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|128.19|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|111.83|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|191|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|136.38|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|122.74|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|122.74|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|0|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|38.19|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|191|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|191|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|191|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75|32.77|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75|66.88|191|32.77
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|191|191|32.77
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AARP [1000]|AARP [100000]|163.2||||163.2|163.2|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AETNA [1015]|AETNA [101529]|163.2||||163.2|73.44|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|163.2||||163.2|81.6|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163.2||||163.2|65.28|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163.2||||163.2|65.28|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163.2||||163.2|76.7|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|163.2||||163.2|66.91|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|163.2||||163.2|65.28|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|163.2||||163.2|163.2|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|163.2||||163.2|81.6|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163.2||||163.2|73.44|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163.2||||163.2|73.44|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163.2||||163.2|0|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|Self-pay|Self-pay|163.2||||163.2|32.64|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|TML [1980]|TML [198000]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163.2||||163.2|22.85|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163.2||||163.2|163.2|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UNICARE [2040]|UNICARE [204000]|163.2||||163.2|163.2|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163.2||||163.2|163.2|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|163.2||||163.2|112.61|163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163.2||||163.2||163.2|22.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|163.2||||163.2|163.2|163.2|22.85
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|256.8||||256.8|191|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|256.8||||256.8|115.56|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|256.8||||256.8|128.4|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|256.8||||256.8|102.72|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|256.8||||256.8|102.72|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|256.8||||256.8|120.7|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|256.8||||256.8|105.29|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|256.8||||256.8|102.72|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|256.8||||256.8|191|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|256.8||||256.8|128.4|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|256.8||||256.8|115.56|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|256.8||||256.8|115.56|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|256.8||||256.8|0|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|256.8||||256.8|51.36|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|TML [1980]|TML [198000]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|256.8||||256.8|35.95|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|256.8||||256.8|191|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|256.8||||256.8|191|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|256.8||||256.8|191|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|256.8||||256.8|177.19|191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|256.8||||256.8||191|35.95
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|256.8||||256.8|191|191|35.95
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AARP [1000]|AARP [100000]|427.14||||427.14|191|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AETNA [1015]|AETNA [101529]|427.14||||427.14|100.83|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AMBETTER [2930]|AMBETTER [293000]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|427.14||||427.14|213.57|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|427.14||||427.14|170.86|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|427.14||||427.14|170.86|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|427.14||||427.14|200.76|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|427.14||||427.14|175.13|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|CIGNA [1260]|CIGNA PPO [126025]|427.14||||427.14|170.86|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|427.14||||427.14|191|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|427.14||||427.14|213.57|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|427.14||||427.14|100.83|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|427.14||||427.14|100.83|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|427.14||||427.14|0|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|Self-pay|Self-pay|427.14||||427.14|85.43|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|TML [1980]|TML [198000]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|427.14||||427.14|59.8|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|427.14||||427.14|191|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|UNICARE [2040]|UNICARE [204000]|427.14||||427.14|191|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|427.14||||427.14|191|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|WEB TPA [2115]|WEB TPA [211500]|427.14||||427.14|294.73|294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|427.14||||427.14||294.73|59.8
42097763|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN PT|1|WORKER'S COMP [2125]|TML WC [212537]|427.14||||427.14|191|294.73|59.8
4210001|EAP||HH PT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|62.88|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|55.89|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|55.89|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|65.67|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|57.29|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|62.88|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|62.88|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|27.95|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||65.67|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|62.88|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|55.89|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|55.89|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|65.67|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|57.29|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|62.88|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|62.88|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|Self-pay|Self-pay|||||139.73|27.95|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|TML [1980]|TML [198000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||65.67|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|62.88|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|55.89|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|55.89|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|65.67|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|57.29|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|62.88|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|62.88|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|27.95|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|TML [1980]|TML [198000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||65.67|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||139.73|62.88|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|55.89|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|55.89|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|65.67|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|57.29|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|62.88|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|62.88|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|Self-pay|Self-pay|||||139.73|27.95|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|TML [1980]|TML [198000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||65.67|27.95
4210004|EAP||HH PT MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|65.67|27.95
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|17.79||||17.79|8.01|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.79||||17.79|8.9|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.79||||17.79|7.12|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.79||||17.79|7.12|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.79||||17.79|8.36|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.79||||17.79|7.29|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|17.79||||17.79|7.12|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.79||||17.79|8.9|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.79||||17.79|8.01|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.79||||17.79|8.01|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|17.79||||17.79|3.56|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.79||||17.79|2.49|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.79||||17.79|0|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|17.79||||17.79|12.28|12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.79||||17.79||12.28|2.49
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|17.79||||17.79|8.01|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.79||||17.79|8.9|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.79||||17.79|7.12|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.79||||17.79|7.12|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.79||||17.79|8.36|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.79||||17.79|7.29|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|17.79||||17.79|7.12|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.79||||17.79|8.9|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.79||||17.79|8.01|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.79||||17.79|8.01|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|17.79||||17.79|3.56|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.79||||17.79|2.49|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.79||||17.79|0|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|17.79||||17.79|12.28|12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.79||||17.79||12.28|2.49
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|17.79||||17.79|0|12.28|2.49
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AARP [1000]|AARP [100000]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AETNA [1015]|AETNA [101529]|47.52||||47.52|21.38|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AMBETTER [2930]|AMBETTER [293000]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.52||||47.52|23.76|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.52||||47.52|19.01|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.52||||47.52|19.01|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.52||||47.52|22.33|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|47.52||||47.52|19.48|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA [1260]|CIGNA PPO [126025]|47.52||||47.52|19.01|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.52||||47.52|23.76|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.52||||47.52|21.38|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.52||||47.52|21.38|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|Self-pay|Self-pay|47.52||||47.52|9.5|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|TML [1980]|TML [198000]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.52||||47.52|6.65|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UNICARE [2040]|UNICARE [204000]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.52||||47.52|0|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WEB TPA [2115]|WEB TPA [211500]|47.52||||47.52|32.79|32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.52||||47.52||32.79|6.65
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WORKER'S COMP [2125]|TML WC [212537]|47.52||||47.52|0|32.79|6.65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|476||||476|191|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|476||||476|131.2|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|476||||476|104.02|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|476||||476|238|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|476||||476|190.4|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|476||||476|190.4|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|476||||476|223.72|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|476||||476|195.16|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|476||||476|190.4|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|476||||476|191|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|476||||476|238|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|476||||476|131.2|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|476||||476|131.2|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|476||||476|0|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|476||||476|95.2|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|TML [1980]|TML [198000]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|476||||476|66.64|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|476||||476|191|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|476||||476|191|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|476||||476|191|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|476||||476|328.44|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|476||||476|97.35|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|476||||476|198.14|328.44|66.64
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|476||||476|191|328.44|66.64
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|611||||611|191|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|611||||611|131.2|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|611||||611|104.02|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|611||||611|305.5|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|611||||611|244.4|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|611||||611|244.4|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|611||||611|287.17|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|611||||611|250.51|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|611||||611|244.4|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|611||||611|191|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|611||||611|305.5|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|611||||611|131.2|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|611||||611|131.2|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|611||||611|0|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|611||||611|122.2|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|TML [1980]|TML [198000]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|611||||611|85.54|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|611||||611|191|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|611||||611|191|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|611||||611|191|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|611||||611|421.59|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|611||||611|97.35|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|611||||611|198.14|421.59|85.54
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|611||||611|191|421.59|85.54
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|747||||747|191|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|747||||747|131.2|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|747||||747|104.02|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|747||||747|373.5|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747||||747|298.8|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747||||747|298.8|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747||||747|351.09|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|747||||747|306.27|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|747||||747|298.8|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|747||||747|191|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|747||||747|373.5|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747||||747|131.2|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747||||747|131.2|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747||||747|0|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|747||||747|149.4|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|TML [1980]|TML [198000]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747||||747|104.58|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747||||747|191|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|747||||747|191|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747||||747|191|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|747||||747|515.43|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747||||747|97.35|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747||||747|198.14|515.43|97.35
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|747||||747|191|515.43|97.35
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|277.2||||277.2|191|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|277.2||||277.2|90.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|71.02|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|138.6|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|110.88|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|110.88|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|130.28|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|113.65|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2|191|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|138.6|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|90.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|90.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|0|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|277.2||||277.2|55.44|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|TML [1980]|TML [198000]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|38.81|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2|191|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNICARE [2040]|UNICARE [204000]|277.2||||277.2|191|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2|191|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2|66.39|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.2||||277.2|135.28|191.27|38.81
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2|191|191.27|38.81
4300001|EAP||HH OT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||140.68|63.31|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|56.27|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|56.27|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|66.12|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|57.68|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|63.31|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|63.31|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|Self-pay|Self-pay|||||140.68|28.14|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|TML [1980]|TML [198000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||66.12|28.14
4300001|EAP||HH OT MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|66.12|28.14
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AARP [1000]|AARP [100000]|116.75||||116.75|116.75|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA [1015]|AETNA [101529]|116.75||||116.75|22.11|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMBETTER [2930]|AMBETTER [293000]|116.75||||116.75||116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|116.75||||116.75|58.38|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.75||||116.75|46.7|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.75||||116.75|46.7|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.75||||116.75|54.87|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|116.75||||116.75|47.87|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA PPO [126025]|116.75||||116.75|46.7|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|116.75||||116.75|116.75|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|116.75||||116.75|58.38|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.75||||116.75|22.11|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.75||||116.75|22.11|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.75||||116.75|0|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|Self-pay|Self-pay|116.75||||116.75|23.35|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|TML [1980]|TML [198000]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.75||||116.75|16.35|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.75||||116.75|116.75|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNICARE [2040]|UNICARE [204000]|116.75||||116.75|116.75|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.75||||116.75|116.75|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WEB TPA [2115]|WEB TPA [211500]|116.75||||116.75|80.56|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.75||||116.75|12.63|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.75||||116.75|25.64|116.75|12.63
43000283|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TML WC [212537]|116.75||||116.75|116.75|116.75|12.63
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AARP [1000]|AARP [100000]|587.65||||587.65|191|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AETNA [1015]|AETNA [101529]|587.65||||587.65|264.44|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AMBETTER [2930]|AMBETTER [293000]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|587.65||||587.65|293.83|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|587.65||||587.65|235.06|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|587.65||||587.65|235.06|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|587.65||||587.65|276.2|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|587.65||||587.65|240.94|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA [1260]|CIGNA PPO [126025]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|587.65||||587.65|191|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|587.65||||587.65|293.83|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|587.65||||587.65|264.44|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|587.65||||587.65|264.44|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|587.65||||587.65|0|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|Self-pay|Self-pay|587.65||||587.65|117.53|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|TML [1980]|TML [198000]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|587.65||||587.65|82.27|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|587.65||||587.65|191|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UNICARE [2040]|UNICARE [204000]|587.65||||587.65|191|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|587.65||||587.65|191|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WEB TPA [2115]|WEB TPA [211500]|587.65||||587.65|405.48|405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|587.65||||587.65||405.48|82.27
43029125|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WORKER'S COMP [2125]|TML WC [212537]|587.65||||587.65|191|405.48|82.27
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AARP [1000]|AARP [100000]|331||||331|191|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AETNA [1015]|AETNA [101529]|331||||331|148.95|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AMBETTER [2930]|AMBETTER [293000]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|331||||331|165.5|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|331||||331|132.4|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|331||||331|132.4|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|331||||331|155.57|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|331||||331|135.71|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|331||||331|132.4|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|331||||331|191|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|331||||331|165.5|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|331||||331|148.95|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|331||||331|148.95|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|331||||331|0|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|Self-pay|Self-pay|331||||331|66.2|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|TML [1980]|TML [198000]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|331||||331|46.34|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|331||||331|191|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|UNICARE [2040]|UNICARE [204000]|331||||331|191|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|331||||331|191|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|WEB TPA [2115]|WEB TPA [211500]|331||||331|228.39|228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|331||||331||228.39|46.34
43095852|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ROM TEST HAND ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|331||||331|191|228.39|46.34
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AARP [1000]|AARP [100000]|233.7||||233.7|191|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AETNA [1015]|AETNA [101529]|233.7||||233.7|18.84|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|233.7||||233.7|116.85|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|233.7||||233.7|93.48|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|233.7||||233.7|93.48|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|233.7||||233.7|109.84|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|233.7||||233.7|95.82|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|233.7||||233.7|93.48|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|233.7||||233.7|191|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|233.7||||233.7|116.85|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|233.7||||233.7|18.84|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|233.7||||233.7|18.84|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|233.7||||233.7|0|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|Self-pay|Self-pay|233.7||||233.7|46.74|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|TML [1980]|TML [198000]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|233.7||||233.7|32.72|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|233.7||||233.7|191|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UNICARE [2040]|UNICARE [204000]|233.7||||233.7|191|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|233.7||||233.7|191|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|233.7||||233.7|161.25|191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|233.7||||233.7||191|18.84
43097016|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC VASOPNEUMATIC DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|233.7||||233.7|191|191|18.84
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AARP [1000]|AARP [100000]|303.75||||303.75|191|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA [1015]|AETNA [101529]|303.75||||303.75|9.05|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMBETTER [2930]|AMBETTER [293000]|303.75||||303.75|5.91|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.75||||303.75|151.88|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.75||||303.75|121.5|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.75||||303.75|121.5|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.75||||303.75|142.76|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.75||||303.75|124.54|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA PPO [126025]|303.75||||303.75|121.5|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.75||||303.75|191|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.75||||303.75|151.88|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.75||||303.75|9.05|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.75||||303.75|9.05|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.75||||303.75|0|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|Self-pay|Self-pay|303.75||||303.75|60.75|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|TML [1980]|TML [198000]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.75||||303.75|42.53|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.75||||303.75|191|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNICARE [2040]|UNICARE [204000]|303.75||||303.75|191|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.75||||303.75|191|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WEB TPA [2115]|WEB TPA [211500]|303.75||||303.75|209.59|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.75||||303.75|5.63|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.75||||303.75|11.26|209.59|5.63
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TML WC [212537]|303.75||||303.75|191|209.59|5.63
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AARP [1000]|AARP [100000]|194.5||||194.5|191|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA [1015]|AETNA [101529]|194.5||||194.5|27.57|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMBETTER [2930]|AMBETTER [293000]|194.5||||194.5|18.34|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|194.5||||194.5|97.25|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194.5||||194.5|77.8|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194.5||||194.5|77.8|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194.5||||194.5|91.42|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|194.5||||194.5|79.75|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA PPO [126025]|194.5||||194.5|77.8|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|194.5||||194.5|191|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|194.5||||194.5|97.25|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194.5||||194.5|27.57|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194.5||||194.5|27.57|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194.5||||194.5|0|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|Self-pay|Self-pay|194.5||||194.5|38.9|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|TML [1980]|TML [198000]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194.5||||194.5|27.23|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194.5||||194.5|191|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNICARE [2040]|UNICARE [204000]|194.5||||194.5|191|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194.5||||194.5|191|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WEB TPA [2115]|WEB TPA [211500]|194.5||||194.5|134.21|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194.5||||194.5|16.97|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194.5||||194.5|34.94|191|16.97
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TML WC [212537]|194.5||||194.5|191|191|16.97
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AARP [1000]|AARP [100000]|545.25||||545.25|191|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA [1015]|AETNA [101529]|545.25||||545.25|22.64|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|545.25||||545.25|15.32|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.25||||545.25|272.63|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.25||||545.25|218.1|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.25||||545.25|218.1|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.25||||545.25|256.27|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.25||||545.25|223.55|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|545.25||||545.25|218.1|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.25||||545.25|191|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.25||||545.25|272.63|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.25||||545.25|22.64|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.25||||545.25|22.64|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.25||||545.25|0|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|Self-pay|Self-pay|545.25||||545.25|109.05|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|TML [1980]|TML [198000]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.25||||545.25|76.34|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.25||||545.25|191|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNICARE [2040]|UNICARE [204000]|545.25||||545.25|191|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.25||||545.25|191|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|545.25||||545.25|376.22|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.25||||545.25|14.45|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.25||||545.25|29.18|376.22|14.45
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|545.25||||545.25|191|376.22|14.45
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AARP [1000]|AARP [100000]|210.6||||210.6|191|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA [1015]|AETNA [101529]|210.6||||210.6|31.9|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210.6||||210.6|105.3|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210.6||||210.6|84.24|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210.6||||210.6|84.24|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210.6||||210.6|98.98|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210.6||||210.6|86.35|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|210.6||||210.6|84.24|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210.6||||210.6|191|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210.6||||210.6|105.3|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210.6||||210.6|31.9|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210.6||||210.6|31.9|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210.6||||210.6|0|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|Self-pay|Self-pay|210.6||||210.6|42.12|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|TML [1980]|TML [198000]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210.6||||210.6|29.48|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210.6||||210.6|191|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|210.6||||210.6|191|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210.6||||210.6|191|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|210.6||||210.6|145.31|191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210.6||||210.6||191|29.48
43097033|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|210.6||||210.6|191|191|29.48
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AARP [1000]|AARP [100000]|210.6||||210.6|191|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AETNA [1015]|AETNA [101529]|210.6||||210.6|23.21|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210.6||||210.6|105.3|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210.6||||210.6|84.24|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210.6||||210.6|84.24|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210.6||||210.6|98.98|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210.6||||210.6|86.35|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|210.6||||210.6|84.24|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210.6||||210.6|191|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210.6||||210.6|105.3|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210.6||||210.6|23.21|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210.6||||210.6|23.21|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210.6||||210.6|0|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|Self-pay|Self-pay|210.6||||210.6|42.12|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|TML [1980]|TML [198000]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210.6||||210.6|29.48|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210.6||||210.6|191|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UNICARE [2040]|UNICARE [204000]|210.6||||210.6|191|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210.6||||210.6|191|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|210.6||||210.6|145.31|191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210.6||||210.6||191|23.21
43097034|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC CONTRAST BATH 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|210.6||||210.6|191|191|23.21
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AARP [1000]|AARP [100000]|163.2||||163.2|163.2|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA [1015]|AETNA [101529]|163.2||||163.2|22.11|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|163.2||||163.2|14.91|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|163.2||||163.2|81.6|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163.2||||163.2|65.28|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163.2||||163.2|65.28|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163.2||||163.2|76.7|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|163.2||||163.2|66.91|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|163.2||||163.2|65.28|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|163.2||||163.2|163.2|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|163.2||||163.2|81.6|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163.2||||163.2|22.11|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163.2||||163.2|22.11|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163.2||||163.2|0|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|Self-pay|Self-pay|163.2||||163.2|32.64|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|TML [1980]|TML [198000]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163.2||||163.2|22.85|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163.2||||163.2|163.2|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNICARE [2040]|UNICARE [204000]|163.2||||163.2|163.2|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163.2||||163.2|163.2|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|163.2||||163.2|112.61|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163.2||||163.2|13.99|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163.2||||163.2|28.4|163.2|13.99
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|163.2||||163.2|163.2|163.2|13.99
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AARP [1000]|AARP [100000]|194.5||||194.5|191|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194.5||||194.5|48.63|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AETNA [1015]|AETNA [101529]|194.5||||194.5|19.41|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AMBETTER [2930]|AMBETTER [293000]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|194.5||||194.5|97.25|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194.5||||194.5|77.8|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194.5||||194.5|77.8|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194.5||||194.5|91.42|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|194.5||||194.5|79.75|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|CIGNA [1260]|CIGNA PPO [126025]|194.5||||194.5|77.8|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|194.5||||194.5|191|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|194.5||||194.5|97.25|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194.5||||194.5|19.41|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194.5||||194.5|19.41|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194.5||||194.5|0|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|Self-pay|Self-pay|194.5||||194.5|38.9|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|TML [1980]|TML [198000]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194.5||||194.5|27.23|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194.5||||194.5|191|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|UNICARE [2040]|UNICARE [204000]|194.5||||194.5|191|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194.5||||194.5|191|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|WEB TPA [2115]|WEB TPA [211500]|194.5||||194.5|134.21|191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194.5||||194.5||191|19.41
43097039|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MODALITY UNLISTED|1|WORKER'S COMP [2125]|TML WC [212537]|194.5||||194.5|191|191|19.41
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|205||||205|191|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|205||||205|46.92|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|205||||205|30.91|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205||||205|102.5|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205||||205|82|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205||||205|82|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205||||205|96.35|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205||||205|84.05|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|205||||205|82|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205||||205|191|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205||||205|102.5|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205||||205|46.92|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205||||205|46.92|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205||||205|0|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|205||||205|41|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TML [1980]|TML [198000]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205||||205|28.7|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205||||205|191|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|205||||205|191|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205||||205|191|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|205||||205|141.45|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205||||205|29.02|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205||||205|58.88|191|28.7
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|205||||205|191|191|28.7
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|246.25||||246.25|191|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|246.25||||246.25|54.01|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|246.25||||246.25|35.89|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|246.25||||246.25|123.13|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246.25||||246.25|98.5|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246.25||||246.25|98.5|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246.25||||246.25|115.74|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|246.25||||246.25|100.96|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|246.25||||246.25|98.5|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|246.25||||246.25|191|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|246.25||||246.25|123.13|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246.25||||246.25|54.01|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246.25||||246.25|54.01|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246.25||||246.25|0|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|246.25||||246.25|49.25|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TML [1980]|TML [198000]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246.25||||246.25|34.48|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246.25||||246.25|191|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNICARE [2040]|UNICARE [204000]|246.25||||246.25|191|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246.25||||246.25|191|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|246.25||||246.25|169.91|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246.25||||246.25|33.58|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246.25||||246.25|68.36|191|33.58
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|246.25||||246.25|191|191|33.58
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AARP [1000]|AARP [100000]|275||||275|191|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA [1015]|AETNA [101529]|275||||275|59.44|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|275||||275|39.01|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|275||||275|137.5|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|275||||275|110|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|275||||275|110|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|275||||275|129.25|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|275||||275|112.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|275||||275|110|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|275||||275|191|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|275||||275|137.5|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|275||||275|59.44|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|275||||275|59.44|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|275||||275|0|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|Self-pay|Self-pay|275||||275|55|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|TML [1980]|TML [198000]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|275||||275|38.5|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|275||||275|191|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNICARE [2040]|UNICARE [204000]|275||||275|191|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|275||||275|191|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|275||||275|189.75|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|275||||275|36.32|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|275||||275|74.3|191|36.32
43097113|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|275||||275|191|191|36.32
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|191|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|44.96|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|30.18|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|160.27|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|160.27|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|188.32|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|164.28|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|191|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|44.96|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|44.96|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|0|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|56.1|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|191|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|191|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|191|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|27.94|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|57.48|276.47|27.94
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|191|276.47|27.94
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AARP [1000]|AARP [100000]|203||||203|191|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA [1015]|AETNA [101529]|203||||203|36.03|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|203||||203|23.99|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203||||203|101.5|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|81.2|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|81.2|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|95.41|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203||||203|83.23|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|203||||203|81.2|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203||||203|191|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203||||203|101.5|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|36.03|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|36.03|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|0|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|Self-pay|Self-pay|203||||203|40.6|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|TML [1980]|TML [198000]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|28.42|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|191|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|203||||203|191|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|191|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|203||||203|140.07|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|22.85|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|45.9|191|22.85
43097129|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|203||||203|191|191|22.85
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|180||||180|180|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|180||||180|43.12|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|180||||180|28.42|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|180||||180|90|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180||||180|72|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180||||180|72|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180||||180|84.6|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|180||||180|73.8|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|180||||180|72|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|180||||180|180|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|180||||180|90|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180||||180|43.12|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180||||180|43.12|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180||||180|0|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|180||||180|36|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TML [1980]|TML [198000]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180||||180|25.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180||||180|180|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|180||||180|180|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180||||180|180|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|180||||180|124.2|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180||||180|26.76|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180||||180|54.14|180|25.2
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|180||||180|180|180|25.2
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AARP [1000]|AARP [100000]|214||||214|191|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA [1015]|AETNA [101529]|214||||214|28.08|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMBETTER [2930]|AMBETTER [293000]|214||||214|18.53|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|214||||214|107|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|85.6|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|85.6|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|100.58|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|214||||214|87.74|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA PPO [126025]|214||||214|85.6|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|214||||214|191|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|214||||214|107|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|28.08|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|28.08|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|0|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|Self-pay|Self-pay|214||||214|42.8|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|TML [1980]|TML [198000]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|29.96|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214|191|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNICARE [2040]|UNICARE [204000]|214||||214|191|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214|191|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WEB TPA [2115]|WEB TPA [211500]|214||||214|147.66|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214|17.4|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214|35.3|191|17.4
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TML WC [212537]|214||||214|191|191|17.4
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|280.8||||280.8|191|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|280.8||||280.8|60.54|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|280.8||||280.8|39.99|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|280.8||||280.8|140.4|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.8||||280.8|112.32|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.8||||280.8|112.32|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.8||||280.8|131.98|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|280.8||||280.8|115.13|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|280.8||||280.8|112.32|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|280.8||||280.8|191|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|280.8||||280.8|140.4|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.8||||280.8|60.54|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.8||||280.8|60.54|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.8||||280.8|0|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|280.8||||280.8|56.16|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TML [1980]|TML [198000]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.8||||280.8|39.31|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.8||||280.8|191|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|280.8||||280.8|191|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.8||||280.8|191|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|280.8||||280.8|193.75|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.8||||280.8|37.11|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.8||||280.8|76.18|193.75|37.11
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|280.8||||280.8|191|193.75|37.11
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AARP [1000]|AARP [100000]|216.5||||216.5|191|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA [1015]|AETNA [101529]|216.5||||216.5|79.59|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.5||||216.5|108.25|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.5||||216.5|86.6|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.5||||216.5|86.6|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.5||||216.5|101.76|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.5||||216.5|88.77|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|216.5||||216.5|86.6|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.5||||216.5|191|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.5||||216.5|108.25|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.5||||216.5|79.59|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.5||||216.5|79.59|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.5||||216.5|0|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|Self-pay|Self-pay|216.5||||216.5|43.3|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|TML [1980]|TML [198000]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.5||||216.5|30.31|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.5||||216.5|191|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNICARE [2040]|UNICARE [204000]|216.5||||216.5|191|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.5||||216.5|191|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|216.5||||216.5|149.39|191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216.5||||216.5||191|30.31
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|216.5||||216.5|191|191|30.31
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AARP [1000]|AARP [100000]|275||||275|191|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|275||||275|52.38|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|275||||275|34.41|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|275||||275|137.5|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|275||||275|110|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|275||||275|110|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|275||||275|129.25|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|275||||275|112.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|275||||275|110|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|275||||275|191|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|275||||275|137.5|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|275||||275|52.38|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|275||||275|52.38|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|275||||275|0|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|Self-pay|Self-pay|275||||275|55|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|TML [1980]|TML [198000]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|275||||275|38.5|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|275||||275|191|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNICARE [2040]|UNICARE [204000]|275||||275|191|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|275||||275|191|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|275||||275|189.75|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|275||||275|32.15|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|275||||275|65.54|191|32.15
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|275||||275|191|191|32.15
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AARP [1000]|AARP [100000]|175.5||||175.5|175.5|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA [1015]|AETNA [101529]|175.5||||175.5|50.75|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|175.5||||175.5|87.75|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175.5||||175.5|70.2|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175.5||||175.5|70.2|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175.5||||175.5|82.49|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|175.5||||175.5|71.96|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|175.5||||175.5|70.2|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|175.5||||175.5|175.5|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|175.5||||175.5|87.75|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175.5||||175.5|50.75|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175.5||||175.5|50.75|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175.5||||175.5|0|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|Self-pay|Self-pay|175.5||||175.5|35.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|TML [1980]|TML [198000]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175.5||||175.5|24.57|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175.5||||175.5|175.5|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|175.5||||175.5|175.5|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175.5||||175.5|175.5|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|175.5||||175.5|121.1|175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175.5||||175.5||175.5|24.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|175.5||||175.5|175.5|175.5|24.57
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AARP [1000]|AARP [100000]|607.8||||607.8|191|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA [1015]|AETNA [101529]|607.8||||607.8|248.42|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMBETTER [2930]|AMBETTER [293000]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|607.8||||607.8|303.9|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|607.8||||607.8|243.12|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|607.8||||607.8|243.12|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|607.8||||607.8|285.67|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|607.8||||607.8|249.2|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA [1260]|CIGNA PPO [126025]|607.8||||607.8|243.12|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|607.8||||607.8|191|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|607.8||||607.8|303.9|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|607.8||||607.8|248.42|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|607.8||||607.8|248.42|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|607.8||||607.8|0|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|Self-pay|Self-pay|607.8||||607.8|121.56|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|TML [1980]|TML [198000]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|607.8||||607.8|85.09|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|607.8||||607.8|191|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNICARE [2040]|UNICARE [204000]|607.8||||607.8|191|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|607.8||||607.8|191|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WEB TPA [2115]|WEB TPA [211500]|607.8||||607.8|419.38|419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|607.8||||607.8||419.38|85.09
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WORKER'S COMP [2125]|TML WC [212537]|607.8||||607.8|191|419.38|85.09
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AARP [1000]|AARP [100000]|303.9||||303.9|191|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA [1015]|AETNA [101529]|303.9||||303.9|99.3|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMBETTER [2930]|AMBETTER [293000]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.9||||303.9|151.95|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.9||||303.9|121.56|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.9||||303.9|121.56|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.9||||303.9|142.83|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.9||||303.9|124.6|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA [1260]|CIGNA PPO [126025]|303.9||||303.9|121.56|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.9||||303.9|191|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.9||||303.9|151.95|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.9||||303.9|99.3|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.9||||303.9|99.3|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.9||||303.9|0|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|Self-pay|Self-pay|303.9||||303.9|60.78|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|TML [1980]|TML [198000]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.9||||303.9|42.55|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.9||||303.9|191|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNICARE [2040]|UNICARE [204000]|303.9||||303.9|191|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.9||||303.9|191|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WEB TPA [2115]|WEB TPA [211500]|303.9||||303.9|209.69|209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.9||||303.9||209.69|42.55
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WORKER'S COMP [2125]|TML WC [212537]|303.9||||303.9|191|209.69|42.55
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|191|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|122.74|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75|35.11|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|136.38|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|109.1|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|109.1|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|128.19|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|111.83|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|191|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|136.38|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|122.74|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|122.74|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|0|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|38.19|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|191|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|191|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|191|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75|32.77|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75|66.88|191|32.77
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|191|191|32.77
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|163.2||||163.2|163.2|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|163.2||||163.2|73.44|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|163.2||||163.2|81.6|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163.2||||163.2|65.28|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163.2||||163.2|65.28|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163.2||||163.2|76.7|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|163.2||||163.2|66.91|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|163.2||||163.2|65.28|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|163.2||||163.2|163.2|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|163.2||||163.2|81.6|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163.2||||163.2|73.44|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163.2||||163.2|73.44|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163.2||||163.2|0|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|163.2||||163.2|32.64|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|TML [1980]|TML [198000]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163.2||||163.2|22.85|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163.2||||163.2|163.2|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|163.2||||163.2|163.2|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163.2||||163.2|163.2|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|163.2||||163.2|112.61|163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163.2||||163.2||163.2|22.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|163.2||||163.2|163.2|163.2|22.85
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|256.8||||256.8|191|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|256.8||||256.8|115.56|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|256.8||||256.8|128.4|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|256.8||||256.8|102.72|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|256.8||||256.8|102.72|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|256.8||||256.8|120.7|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|256.8||||256.8|105.29|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|256.8||||256.8|102.72|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|256.8||||256.8|191|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|256.8||||256.8|128.4|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|256.8||||256.8|115.56|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|256.8||||256.8|115.56|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|256.8||||256.8|0|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|256.8||||256.8|51.36|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|TML [1980]|TML [198000]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|256.8||||256.8|35.95|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|256.8||||256.8|191|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|256.8||||256.8|191|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|256.8||||256.8|191|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|256.8||||256.8|177.19|191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|256.8||||256.8||191|35.95
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|256.8||||256.8|191|191|35.95
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AARP [1000]|AARP [100000]|427.14||||427.14|191|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AETNA [1015]|AETNA [101529]|427.14||||427.14|100.83|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AMBETTER [2930]|AMBETTER [293000]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|427.14||||427.14|213.57|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|427.14||||427.14|170.86|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|427.14||||427.14|170.86|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|427.14||||427.14|200.76|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|427.14||||427.14|175.13|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|CIGNA [1260]|CIGNA PPO [126025]|427.14||||427.14|170.86|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|427.14||||427.14|191|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|427.14||||427.14|213.57|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|427.14||||427.14|100.83|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|427.14||||427.14|100.83|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|427.14||||427.14|0|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|Self-pay|Self-pay|427.14||||427.14|85.43|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|TML [1980]|TML [198000]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|427.14||||427.14|59.8|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|427.14||||427.14|191|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|UNICARE [2040]|UNICARE [204000]|427.14||||427.14|191|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|427.14||||427.14|191|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|WEB TPA [2115]|WEB TPA [211500]|427.14||||427.14|294.73|294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|427.14||||427.14||294.73|59.8
43097763|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHC/PROSTC MGMT SBSQ ENC EA 15 MIN OT|1|WORKER'S COMP [2125]|TML WC [212537]|427.14||||427.14|191|294.73|59.8
4310001|EAP||HH OT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|63.31|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|56.27|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|56.27|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|66.12|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|57.68|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|63.31|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|63.31|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|28.14|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||66.12|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|63.31|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|56.27|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|56.27|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|66.12|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|57.68|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|63.31|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|63.31|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|Self-pay|Self-pay|||||140.68|28.14|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|TML [1980]|TML [198000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||66.12|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|63.31|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|56.27|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|56.27|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|66.12|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|57.68|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|63.31|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|63.31|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|28.14|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|TML [1980]|TML [198000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||66.12|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|66.12|28.14
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|396||||396|191|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|396||||396|139.36|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|396||||396|100.87|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|396||||396|198|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|158.4|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|158.4|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|186.12|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|396||||396|162.36|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|396||||396|158.4|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|396||||396|191|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|396||||396|198|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|139.36|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|139.36|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|0|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|396||||396|79.2|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|TML [1980]|TML [198000]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|55.44|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396|191|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|396||||396|191|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396|191|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|396||||396|273.24|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396|94.54|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396|192.14|273.24|55.44
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|396||||396|191|273.24|55.44
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|641.34||||641.34|191|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|641.34||||641.34|138.82|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|641.34||||641.34|100.87|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641.34||||641.34|320.67|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641.34||||641.34|256.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641.34||||641.34|256.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641.34||||641.34|301.43|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641.34||||641.34|262.95|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|641.34||||641.34|256.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641.34||||641.34|191|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641.34||||641.34|320.67|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641.34||||641.34|138.82|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641.34||||641.34|138.82|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641.34||||641.34|0|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|641.34||||641.34|128.27|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|TML [1980]|TML [198000]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641.34||||641.34|89.79|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641.34||||641.34|191|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|641.34||||641.34|191|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641.34||||641.34|191|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|641.34||||641.34|442.52|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641.34||||641.34|94.54|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|641.34||||641.34|192.14|442.52|89.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|641.34||||641.34|191|442.52|89.79
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|783.72||||783.72|191|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|783.72||||783.72|138.82|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.72||||783.72|391.86|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.72||||783.72|313.49|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.72||||783.72|313.49|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.72||||783.72|368.35|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.72||||783.72|321.33|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|783.72||||783.72|313.49|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.72||||783.72|191|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.72||||783.72|391.86|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.72||||783.72|138.82|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.72||||783.72|138.82|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.72||||783.72|0|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|783.72||||783.72|156.74|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|TML [1980]|TML [198000]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.72||||783.72|109.72|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.72||||783.72|191|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|783.72||||783.72|191|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.72||||783.72|191|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|783.72||||783.72|540.77|540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|783.72||||783.72||540.77|109.72
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|783.72||||783.72|191|540.77|109.72
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|277.2||||277.2|191|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|277.2||||277.2|96.24|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|138.6|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|110.88|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|110.88|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|130.28|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|113.65|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2|191|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|138.6|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|96.24|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|96.24|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|0|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|277.2||||277.2|55.44|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|TML [1980]|TML [198000]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|38.81|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2|191|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNICARE [2040]|UNICARE [204000]|277.2||||277.2|191|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2|191|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.2||||277.2||191.27|38.81
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2|191|191.27|38.81
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.56||||7.56|3.4|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.56||||7.56|3.78|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.56||||7.56|3.02|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.56||||7.56|3.02|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.56||||7.56|3.55|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.56||||7.56|3.1|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.56||||7.56|3.02|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.56||||7.56|3.78|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.56||||7.56|3.4|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.56||||7.56|3.4|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|7.56||||7.56|1.51|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.56||||7.56|1.06|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.56||||7.56|0|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.56||||7.56|5.22|5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.56||||7.56||5.22|1.06
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.56||||7.56|0|5.22|1.06
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AARP [1000]|AARP [100000]|709||||709|191|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA [1015]|AETNA [101529]|709||||709|102.56|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMBETTER [2930]|AMBETTER [293000]|709||||709|79.84|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|709||||709|354.5|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|709||||709|283.6|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|709||||709|283.6|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|709||||709|333.23|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|709||||709|290.69|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA [1260]|CIGNA PPO [126025]|709||||709|283.6|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|709||||709|191|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|709||||709|354.5|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|709||||709|102.56|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|709||||709|102.56|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|709||||709|0|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|Self-pay|Self-pay|709||||709|141.8|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|TML [1980]|TML [198000]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|709||||709|99.26|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|709||||709|191|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNICARE [2040]|UNICARE [204000]|709||||709|191|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|709||||709|191|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WEB TPA [2115]|WEB TPA [211500]|709||||709|489.21|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|709||||709|75.22|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|709||||709|152.08|489.21|75.22
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WORKER'S COMP [2125]|TML WC [212537]|709||||709|191|489.21|75.22
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AARP [1000]|AARP [100000]|399.25||||399.25|191|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA [1015]|AETNA [101529]|399.25||||399.25|179.66|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMBETTER [2930]|AMBETTER [293000]|399.25||||399.25|88.31|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|399.25||||399.25|199.63|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|399.25||||399.25|159.7|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|399.25||||399.25|159.7|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|399.25||||399.25|187.65|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|399.25||||399.25|163.69|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA [1260]|CIGNA PPO [126025]|399.25||||399.25|159.7|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|399.25||||399.25|191|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|399.25||||399.25|199.63|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|399.25||||399.25|179.66|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|399.25||||399.25|179.66|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|399.25||||399.25|0|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|Self-pay|Self-pay|399.25||||399.25|79.85|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|TML [1980]|TML [198000]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|399.25||||399.25|55.9|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|399.25||||399.25|191|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNICARE [2040]|UNICARE [204000]|399.25||||399.25|191|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|399.25||||399.25|191|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WEB TPA [2115]|WEB TPA [211500]|399.25||||399.25|275.48|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|399.25||||399.25|82.87|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|399.25||||399.25|168.2|275.48|55.9
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WORKER'S COMP [2125]|TML WC [212537]|399.25||||399.25|191|275.48|55.9
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AARP [1000]|AARP [100000]|292.5||||292.5|191|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AETNA [1015]|AETNA [101529]|292.5||||292.5|131.63|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AMBETTER [2930]|AMBETTER [293000]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|292.5||||292.5|146.25|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|292.5||||292.5|117|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|292.5||||292.5|117|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|292.5||||292.5|137.48|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|292.5||||292.5|119.93|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|CIGNA [1260]|CIGNA PPO [126025]|292.5||||292.5|117|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|292.5||||292.5|191|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|292.5||||292.5|146.25|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|292.5||||292.5|131.63|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|292.5||||292.5|131.63|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|292.5||||292.5|0|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|Self-pay|Self-pay|292.5||||292.5|58.5|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|TML [1980]|TML [198000]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|292.5||||292.5|40.95|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|292.5||||292.5|191|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|UNICARE [2040]|UNICARE [204000]|292.5||||292.5|191|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|292.5||||292.5|191|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|WEB TPA [2115]|WEB TPA [211500]|292.5||||292.5|201.83|201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|292.5||||292.5||201.83|40.95
44092609|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH GEN DEVICE PRG/MOD|1|WORKER'S COMP [2125]|TML WC [212537]|292.5||||292.5|191|201.83|40.95
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AARP [1000]|AARP [100000]|744.75||||744.75|191|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AETNA [1015]|AETNA [101529]|744.75||||744.75|335.14|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AMBETTER [2930]|AMBETTER [293000]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|744.75||||744.75|372.38|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|744.75||||744.75|297.9|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|744.75||||744.75|297.9|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|744.75||||744.75|350.03|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|744.75||||744.75|305.35|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|CIGNA [1260]|CIGNA PPO [126025]|744.75||||744.75|297.9|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|744.75||||744.75|191|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|744.75||||744.75|372.38|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|744.75||||744.75|335.14|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|744.75||||744.75|335.14|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|744.75||||744.75|0|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|Self-pay|Self-pay|744.75||||744.75|148.95|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|TML [1980]|TML [198000]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|744.75||||744.75|104.27|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|744.75||||744.75|191|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|UNICARE [2040]|UNICARE [204000]|744.75||||744.75|191|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|744.75||||744.75|191|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|WEB TPA [2115]|WEB TPA [211500]|744.75||||744.75|513.88|513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|744.75||||744.75||513.88|104.27
44092612|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC EVAL SWALLOWING ENDOSCOPIC|1|WORKER'S COMP [2125]|TML WC [212537]|744.75||||744.75|191|513.88|104.27
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AARP [1000]|AARP [100000]|536||||536|191|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AETNA [1015]|AETNA [101529]|536||||536|241.2|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AMBETTER [2930]|AMBETTER [293000]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|536||||536|268|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|536||||536|214.4|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|536||||536|214.4|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|536||||536|251.92|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|536||||536|219.76|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|CIGNA [1260]|CIGNA PPO [126025]|536||||536|214.4|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|536||||536|191|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|536||||536|268|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|536||||536|241.2|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|536||||536|241.2|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|536||||536|0|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|Self-pay|Self-pay|536||||536|107.2|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|TML [1980]|TML [198000]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|536||||536|75.04|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|536||||536|191|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|UNICARE [2040]|UNICARE [204000]|536||||536|191|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|536||||536|191|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|WEB TPA [2115]|WEB TPA [211500]|536||||536|369.84|369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|536||||536||369.84|75.04
44096105|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC APHASIA ASSESSMENT PER HOUR|1|WORKER'S COMP [2125]|TML WC [212537]|536||||536|191|369.84|75.04
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AARP [1000]|AARP [100000]|203||||203|191|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA [1015]|AETNA [101529]|203||||203|36.03|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|203||||203|23.99|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203||||203|101.5|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|81.2|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|81.2|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|95.41|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203||||203|83.23|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|203||||203|81.2|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203||||203|191|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203||||203|101.5|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|36.03|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|36.03|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|0|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|Self-pay|Self-pay|203||||203|40.6|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|TML [1980]|TML [198000]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|28.42|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|191|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|203||||203|191|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|191|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|203||||203|140.07|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|22.85|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|45.9|191|22.85
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|203||||203|191|191|22.85
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AARP [1000]|AARP [100000]|203||||203|191|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA [1015]|AETNA [101529]|203||||203|34.96|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|203||||203|22.91|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203||||203|101.5|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|81.2|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|81.2|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|95.41|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|203||||203|83.23|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|203||||203|81.2|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203||||203|191|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203||||203|101.5|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|34.96|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|34.96|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|0|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|Self-pay|Self-pay|203||||203|40.6|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|TML [1980]|TML [198000]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|28.42|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|191|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|203||||203|191|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|191|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|203||||203|140.07|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|21.82|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|43.88|191|21.82
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|203||||203|191|191|21.82
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AARP [1000]|AARP [100000]|259.25||||259.25|191|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA [1015]|AETNA [101529]|259.25||||259.25|50.18|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|259.25||||259.25|129.63|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259.25||||259.25|103.7|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259.25||||259.25|103.7|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259.25||||259.25|121.85|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|259.25||||259.25|106.29|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|259.25||||259.25|103.7|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|259.25||||259.25|191|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|259.25||||259.25|129.63|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259.25||||259.25|50.18|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259.25||||259.25|50.18|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259.25||||259.25|0|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|Self-pay|Self-pay|259.25||||259.25|51.85|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|TML [1980]|TML [198000]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259.25||||259.25|36.3|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259.25||||259.25|191|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNICARE [2040]|UNICARE [204000]|259.25||||259.25|191|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259.25||||259.25|191|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|259.25||||259.25|178.88|191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259.25||||259.25||191|36.3
44097537|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|259.25||||259.25|191|191|36.3
4410001|EAP||HH SLP ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|68.33|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|60.74|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|60.74|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|71.37|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|62.26|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|68.33|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|68.33|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|Self-pay|Self-pay|||||151.85|30.37|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|TML [1980]|TML [198000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||71.37|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|68.33|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|60.74|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|60.74|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|71.37|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|62.26|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|68.33|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|68.33|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|Self-pay|Self-pay|||||151.85|30.37|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|TML [1980]|TML [198000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||71.37|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AARP [1000]|AARP [100000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||151.85|68.33|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|60.74|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|60.74|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|71.37|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|62.26|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|68.33|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|68.33|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|Self-pay|Self-pay|||||151.85|30.37|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|TML [1980]|TML [198000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||71.37|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|71.37|30.37
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.8||||5.8|2.61|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.8||||5.8|2.9|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.8||||5.8|2.32|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.8||||5.8|2.32|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.8||||5.8|2.73|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.8||||5.8|2.38|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.8||||5.8|2.32|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.8||||5.8|2.9|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.8||||5.8|2.61|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.8||||5.8|2.61|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|Self-pay|Self-pay|5.8||||5.8|1.16|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|TML [1980]|TML [198000]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.8||||5.8|0.81|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.8||||5.8|0|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.8||||5.8|4|4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.8||||5.8||4|0.81
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.8||||5.8|0|4|0.81
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.58||||6.58|2.96|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.58||||6.58|3.29|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.58||||6.58|2.63|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.58||||6.58|2.63|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.58||||6.58|3.09|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.58||||6.58|2.7|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.58||||6.58|2.63|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.58||||6.58|3.29|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.58||||6.58|2.96|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.58||||6.58|2.96|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|Self-pay|Self-pay|6.58||||6.58|1.32|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|TML [1980]|TML [198000]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.58||||6.58|0.92|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.58||||6.58|0|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.58||||6.58|4.54|4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.58||||6.58||4.54|0.92
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.58||||6.58|0|4.54|0.92
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.26||||7.26|3.27|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.26||||7.26|3.63|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.26||||7.26|2.9|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.26||||7.26|2.9|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.26||||7.26|3.41|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.26||||7.26|2.98|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.26||||7.26|2.9|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.26||||7.26|3.63|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.26||||7.26|3.27|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.26||||7.26|3.27|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|Self-pay|Self-pay|7.26||||7.26|1.45|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|TML [1980]|TML [198000]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.26||||7.26|1.02|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.26||||7.26|0|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.26||||7.26|5.01|5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.26||||7.26||5.01|1.02
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.26||||7.26|0|5.01|1.02
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.45||||7.45|3.35|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.45||||7.45|3.73|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.45||||7.45|2.98|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.45||||7.45|2.98|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.45||||7.45|3.5|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.45||||7.45|3.05|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.45||||7.45|2.98|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.45||||7.45|3.73|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.45||||7.45|3.35|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.45||||7.45|3.35|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|Self-pay|Self-pay|7.45||||7.45|1.49|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|TML [1980]|TML [198000]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.45||||7.45|1.04|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.45||||7.45|0|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.45||||7.45|5.14|5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.45||||7.45||5.14|1.04
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.45||||7.45|0|5.14|1.04
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.76||||8.76|3.94|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.76||||8.76|4.38|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.76||||8.76|3.5|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.76||||8.76|3.5|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.76||||8.76|4.12|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.76||||8.76|3.59|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.76||||8.76|3.5|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.76||||8.76|4.38|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.76||||8.76|3.94|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.76||||8.76|3.94|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|Self-pay|Self-pay|8.76||||8.76|1.75|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|TML [1980]|TML [198000]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.76||||8.76|1.23|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.76||||8.76|0|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.76||||8.76|6.04|6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.76||||8.76||6.04|1.23
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.76||||8.76|0|6.04|1.23
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AARP [1000]|AARP [100000]|594.97||||594.97|191|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA [1015]|AETNA [101529]|594.97||||594.97|267.74|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMBETTER [2930]|AMBETTER [293000]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.97||||594.97|297.49|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.97||||594.97|237.99|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.97||||594.97|237.99|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.97||||594.97|279.64|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.97||||594.97|243.94|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA [1260]|CIGNA PPO [126025]|594.97||||594.97|237.99|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.97||||594.97|191|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.97||||594.97|297.49|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.97||||594.97|267.74|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.97||||594.97|267.74|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.97||||594.97|0|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|Self-pay|Self-pay|594.97||||594.97|118.99|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|TML [1980]|TML [198000]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.97||||594.97|83.3|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.97||||594.97|191|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNICARE [2040]|UNICARE [204000]|594.97||||594.97|191|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.97||||594.97|191|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WEB TPA [2115]|WEB TPA [211500]|594.97||||594.97|410.53|410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.97||||594.97||410.53|83.3
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WORKER'S COMP [2125]|TML WC [212537]|594.97||||594.97|191|410.53|83.3
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AARP [1000]|AARP [100000]|489.75||||489.75|191|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AETNA [1015]|AETNA [101529]|489.75||||489.75|31.08|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AMBETTER [2930]|AMBETTER [293000]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|489.75||||489.75|244.88|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|489.75||||489.75|195.9|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|489.75||||489.75|195.9|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|489.75||||489.75|230.18|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|489.75||||489.75|200.8|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|CIGNA [1260]|CIGNA PPO [126025]|489.75||||489.75|195.9|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|489.75||||489.75|191|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|489.75||||489.75|244.88|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|489.75||||489.75|31.08|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|489.75||||489.75|31.08|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|489.75||||489.75|0|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|Self-pay|Self-pay|489.75||||489.75|97.95|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|TML [1980]|TML [198000]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|489.75||||489.75|68.57|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|489.75||||489.75|191|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|UNICARE [2040]|UNICARE [204000]|489.75||||489.75|191|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|489.75||||489.75|191|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|WEB TPA [2115]|WEB TPA [211500]|489.75||||489.75|337.93|337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|489.75||||489.75||337.93|31.08
44392508|EAP|0443 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GROUP RAT|HC SPEECH THERAPY GROUP|1|WORKER'S COMP [2125]|TML WC [212537]|489.75||||489.75|191|337.93|31.08
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AARP [1000]|AARP [100000]|562.5||||562.5|191|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA [1015]|AETNA [101529]|562.5||||562.5|146.19|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMBETTER [2930]|AMBETTER [293000]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|562.5||||562.5|281.25|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|562.5||||562.5|225|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|562.5||||562.5|225|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|562.5||||562.5|264.38|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|562.5||||562.5|230.63|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA [1260]|CIGNA PPO [126025]|562.5||||562.5|225|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|562.5||||562.5|191|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|562.5||||562.5|281.25|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|562.5||||562.5|146.19|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|562.5||||562.5|146.19|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|562.5||||562.5|0|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|Self-pay|Self-pay|562.5||||562.5|112.5|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|TML [1980]|TML [198000]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|562.5||||562.5|78.75|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|562.5||||562.5|191|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNICARE [2040]|UNICARE [204000]|562.5||||562.5|191|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|562.5||||562.5|191|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WEB TPA [2115]|WEB TPA [211500]|562.5||||562.5|388.13|388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|562.5||||562.5||388.13|78.75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WORKER'S COMP [2125]|TML WC [212537]|562.5||||562.5|191|388.13|78.75
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AARP [1000]|AARP [100000]|554.48||||554.48|191|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA [1015]|AETNA [101529]|554.48||||554.48|119.06|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMBETTER [2930]|AMBETTER [293000]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|554.48||||554.48|277.24|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|554.48||||554.48|221.79|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|554.48||||554.48|221.79|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|554.48||||554.48|260.61|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|554.48||||554.48|227.34|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA [1260]|CIGNA PPO [126025]|554.48||||554.48|221.79|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|554.48||||554.48|191|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|554.48||||554.48|277.24|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|554.48||||554.48|119.06|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|554.48||||554.48|119.06|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|554.48||||554.48|0|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|Self-pay|Self-pay|554.48||||554.48|110.9|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|TML [1980]|TML [198000]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|554.48||||554.48|77.63|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|554.48||||554.48|191|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNICARE [2040]|UNICARE [204000]|554.48||||554.48|191|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|554.48||||554.48|191|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WEB TPA [2115]|WEB TPA [211500]|554.48||||554.48|382.59|382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|554.48||||554.48||382.59|77.63
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WORKER'S COMP [2125]|TML WC [212537]|554.48||||554.48|191|382.59|77.63
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AARP [1000]|AARP [100000]|1115.7||||1115.7|191|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA [1015]|AETNA [101529]|1115.7||||1115.7|250.89|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMBETTER [2930]|AMBETTER [293000]|1115.7||||1115.7|240.11|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1115.7||||1115.7|557.85|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1115.7||||1115.7|446.28|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1115.7||||1115.7|446.28|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1115.7||||1115.7|524.38|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1115.7||||1115.7|457.44|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA [1260]|CIGNA PPO [126025]|1115.7||||1115.7|446.28|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1115.7||||1115.7|191|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1115.7||||1115.7|557.85|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1115.7||||1115.7|250.89|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1115.7||||1115.7|250.89|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1115.7||||1115.7|0|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|Self-pay|Self-pay|1115.7||||1115.7|223.14|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|TML [1980]|TML [198000]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1115.7||||1115.7|156.2|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1115.7||||1115.7|191|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNICARE [2040]|UNICARE [204000]|1115.7||||1115.7|191|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1115.7||||1115.7|191|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WEB TPA [2115]|WEB TPA [211500]|1115.7||||1115.7|769.83|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1115.7||||1115.7|226.07|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1115.7||||1115.7|457.36|769.83|156.2
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WORKER'S COMP [2125]|TML WC [212537]|1115.7||||1115.7|191|769.83|156.2
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AARP [1000]|AARP [100000]|594.97||||594.97|191|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA [1015]|AETNA [101529]|594.97||||594.97|116.31|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMBETTER [2930]|AMBETTER [293000]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.97||||594.97|297.49|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.97||||594.97|237.99|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.97||||594.97|237.99|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.97||||594.97|279.64|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.97||||594.97|243.94|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA [1260]|CIGNA PPO [126025]|594.97||||594.97|237.99|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.97||||594.97|191|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.97||||594.97|297.49|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.97||||594.97|116.31|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.97||||594.97|116.31|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.97||||594.97|0|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|Self-pay|Self-pay|594.97||||594.97|118.99|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|TML [1980]|TML [198000]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.97||||594.97|83.3|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.97||||594.97|191|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNICARE [2040]|UNICARE [204000]|594.97||||594.97|191|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.97||||594.97|191|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WEB TPA [2115]|WEB TPA [211500]|594.97||||594.97|410.53|410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.97||||594.97||410.53|83.3
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WORKER'S COMP [2125]|TML WC [212537]|594.97||||594.97|191|410.53|83.3
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AARP [1000]|AARP [100000]|747.92||||747.92|191|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AETNA [1015]|AETNA [101529]|747.92||||747.92|336.56|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|747.92||||747.92|373.96|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747.92||||747.92|299.17|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747.92||||747.92|299.17|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747.92||||747.92|351.52|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|747.92||||747.92|306.65|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|747.92||||747.92|299.17|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|747.92||||747.92|191|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|747.92||||747.92|373.96|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747.92||||747.92|336.56|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747.92||||747.92|336.56|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747.92||||747.92|0|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|Self-pay|Self-pay|747.92||||747.92|149.58|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|TML [1980]|TML [198000]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747.92||||747.92|104.71|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747.92||||747.92|191|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNICARE [2040]|UNICARE [204000]|747.92||||747.92|191|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747.92||||747.92|191|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|747.92||||747.92|516.06|516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747.92||||747.92||516.06|104.71
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|747.92||||747.92|191|516.06|104.71
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AARP [1000]|AARP [100000]|572.25||||572.25|191|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AETNA [1015]|AETNA [101529]|572.25||||572.25|257.51|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AMBETTER [2930]|AMBETTER [293000]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|572.25||||572.25|286.13|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|572.25||||572.25|228.9|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|572.25||||572.25|228.9|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|572.25||||572.25|268.96|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|572.25||||572.25|234.62|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|CIGNA [1260]|CIGNA PPO [126025]|572.25||||572.25|228.9|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|572.25||||572.25|191|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|572.25||||572.25|286.13|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|572.25||||572.25|257.51|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|572.25||||572.25|257.51|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|572.25||||572.25|0|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|Self-pay|Self-pay|572.25||||572.25|114.45|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|TML [1980]|TML [198000]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|572.25||||572.25|80.12|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|572.25||||572.25|191|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|UNICARE [2040]|UNICARE [204000]|572.25||||572.25|191|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|572.25||||572.25|191|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|WEB TPA [2115]|WEB TPA [211500]|572.25||||572.25|394.85|394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|572.25||||572.25||394.85|80.12
44492607|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEVICE 1ST HR|1|WORKER'S COMP [2125]|TML WC [212537]|572.25||||572.25|191|394.85|80.12
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AARP [1000]|AARP [100000]|132.75||||132.75|132.75|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AETNA [1015]|AETNA [101529]|132.75||||132.75|59.74|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AMBETTER [2930]|AMBETTER [293000]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132.75||||132.75|66.38|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132.75||||132.75|53.1|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132.75||||132.75|53.1|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132.75||||132.75|62.39|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132.75||||132.75|54.43|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|CIGNA [1260]|CIGNA PPO [126025]|132.75||||132.75|53.1|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132.75||||132.75|132.75|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132.75||||132.75|66.38|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.75||||132.75|59.74|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.75||||132.75|59.74|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.75||||132.75|0|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|Self-pay|Self-pay|132.75||||132.75|26.55|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|TML [1980]|TML [198000]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132.75||||132.75|18.59|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.75||||132.75|132.75|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|UNICARE [2040]|UNICARE [204000]|132.75||||132.75|132.75|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.75||||132.75|132.75|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|WEB TPA [2115]|WEB TPA [211500]|132.75||||132.75|91.6|132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132.75||||132.75||132.75|18.59
44492608|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL AUG/ALT COM DEV ADD 30MIN|1|WORKER'S COMP [2125]|TML WC [212537]|132.75||||132.75|132.75|132.75|18.59
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AARP [1000]|AARP [100000]|826.65||||826.65|191|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA [1015]|AETNA [101529]|826.65||||826.65|371.99|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMBETTER [2930]|AMBETTER [293000]|826.65||||826.65|72.49|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|826.65||||826.65|413.33|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|826.65||||826.65|330.66|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|826.65||||826.65|330.66|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|826.65||||826.65|388.53|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|826.65||||826.65|338.93|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA [1260]|CIGNA PPO [126025]|826.65||||826.65|330.66|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|826.65||||826.65|191|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|826.65||||826.65|413.33|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|826.65||||826.65|371.99|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|826.65||||826.65|371.99|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|826.65||||826.65|0|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|Self-pay|Self-pay|826.65||||826.65|165.33|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|TML [1980]|TML [198000]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|826.65||||826.65|115.73|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|826.65||||826.65|191|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNICARE [2040]|UNICARE [204000]|826.65||||826.65|191|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|826.65||||826.65|191|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WEB TPA [2115]|WEB TPA [211500]|826.65||||826.65|570.39|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|826.65||||826.65|69.04|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|826.65||||826.65|137.3|570.39|69.04
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WORKER'S COMP [2125]|TML WC [212537]|826.65||||826.65|191|570.39|69.04
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AARP [1000]|AARP [100000]|826.65||||826.65|191|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA [1015]|AETNA [101529]|826.65||||826.65|371.99|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMBETTER [2930]|AMBETTER [293000]|826.65||||826.65|95.11|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|826.65||||826.65|413.33|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|826.65||||826.65|330.66|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|826.65||||826.65|330.66|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|826.65||||826.65|388.53|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|826.65||||826.65|338.93|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA [1260]|CIGNA PPO [126025]|826.65||||826.65|330.66|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|826.65||||826.65|191|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|826.65||||826.65|413.33|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|826.65||||826.65|371.99|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|826.65||||826.65|371.99|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|826.65||||826.65|0|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|Self-pay|Self-pay|826.65||||826.65|165.33|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|TML [1980]|TML [198000]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|826.65||||826.65|115.73|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|826.65||||826.65|191|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNICARE [2040]|UNICARE [204000]|826.65||||826.65|191|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|826.65||||826.65|191|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WEB TPA [2115]|WEB TPA [211500]|826.65||||826.65|570.39|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|826.65||||826.65|90.58|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|826.65||||826.65|179.62|570.39|90.58
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WORKER'S COMP [2125]|TML WC [212537]|826.65||||826.65|191|570.39|90.58
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AARP [1000]|AARP [100000]|690.5||||690.5|191|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AETNA [1015]|AETNA [101529]|690.5||||690.5|310.73|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AMBETTER [2930]|AMBETTER [293000]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|690.5||||690.5|345.25|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|690.5||||690.5|276.2|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|690.5||||690.5|276.2|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|690.5||||690.5|324.54|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|690.5||||690.5|283.11|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|CIGNA [1260]|CIGNA PPO [126025]|690.5||||690.5|276.2|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|690.5||||690.5|191|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|690.5||||690.5|345.25|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|690.5||||690.5|310.73|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|690.5||||690.5|310.73|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|690.5||||690.5|0|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|Self-pay|Self-pay|690.5||||690.5|138.1|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|TML [1980]|TML [198000]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|690.5||||690.5|96.67|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|690.5||||690.5|191|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|UNICARE [2040]|UNICARE [204000]|690.5||||690.5|191|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|690.5||||690.5|191|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|WEB TPA [2115]|WEB TPA [211500]|690.5||||690.5|476.45|476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|690.5||||690.5||476.45|96.67
44492614|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC LARYNGEAL FLX FEE SENSORY TEST|1|WORKER'S COMP [2125]|TML WC [212537]|690.5||||690.5|191|476.45|96.67
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AARP [1000]|AARP [100000]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|528||||528|237.6|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528||||528|264|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528||||528|211.2|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528||||528|211.2|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528||||528|248.16|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528||||528|216.48|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|528||||528|211.2|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528||||528|264|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|237.6|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528||||528|237.6|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|Self-pay|Self-pay|528||||528|105.6|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|TML [1980]|TML [198000]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528||||528|73.92|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528||||528|0|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|528||||528|364.32|364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528||||528||364.32|73.92
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|528||||528|0|364.32|73.92
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|44.09||||44.09|19.84|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.09||||44.09|22.05|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.09||||44.09|17.64|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.09||||44.09|17.64|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.09||||44.09|20.72|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.09||||44.09|18.08|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|44.09||||44.09|17.64|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.09||||44.09|22.05|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.09||||44.09|19.84|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.09||||44.09|19.84|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|44.09||||44.09|8.82|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|TML [1980]|TML [198000]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.09||||44.09|6.17|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.09||||44.09|0|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|44.09||||44.09|30.42|30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.09||||44.09||30.42|6.17
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|44.09||||44.09|0|30.42|6.17
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|46.73||||46.73|21.03|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMBETTER [2930]|AMBETTER [293000]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.73||||46.73|23.37|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.73||||46.73|18.69|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.73||||46.73|18.69|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.73||||46.73|21.96|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.73||||46.73|19.16|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|46.73||||46.73|18.69|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.73||||46.73|23.37|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.73||||46.73|21.03|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.73||||46.73|21.03|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|46.73||||46.73|9.35|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|TML [1980]|TML [198000]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.73||||46.73|6.54|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNICARE [2040]|UNICARE [204000]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.73||||46.73|0|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WEB TPA [2115]|WEB TPA [211500]|46.73||||46.73|32.24|32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.73||||46.73||32.24|6.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|46.73||||46.73|0|32.24|6.54
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.68|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.52||||1.52|0.76|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.61|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.61|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.71|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.52||||1.52|0.62|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.52||||1.52|0.61|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.52||||1.52|0.76|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.68|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.68|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.52||||1.52|0.3|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.21|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52|0|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.52||||1.52|1.05|1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.21
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.52||||1.52|0|1.05|0.21
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.95||||3.95|1.78|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.95||||3.95|1.98|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.95||||3.95|1.58|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.95||||3.95|1.58|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.95||||3.95|1.86|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.95||||3.95|1.62|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.95||||3.95|1.58|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.95||||3.95|1.98|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.95||||3.95|1.78|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.95||||3.95|1.78|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|Self-pay|Self-pay|3.95||||3.95|0.79|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|TML [1980]|TML [198000]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.95||||3.95|0.55|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.95||||3.95|0|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.95||||3.95|2.73|2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.95||||3.95||2.73|0.55
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.95||||3.95|0|2.73|0.55
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AARP [1000]|AARP [100000]|2991.12||||2991.12|1495|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AETNA [1015]|AETNA [101529]|2991.12||||2991.12|1346|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AMBETTER [2930]|AMBETTER [293000]|2991.12||||2991.12|346.33|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2991.12||||2991.12|1495.56|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2991.12||||2991.12|1196.45|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2991.12||||2991.12|1196.45|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2991.12||||2991.12|1405.83|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2991.12||||2991.12|1226.36|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA [1260]|CIGNA PPO [126025]|2991.12||||2991.12|2646|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2991.12||||2991.12|1495|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2991.12||||2991.12|1495.56|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2991.12||||2991.12|1346|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2991.12||||2991.12|1346|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2991.12||||2991.12|0|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|Self-pay|Self-pay|2991.12||||2991.12|598.22|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|TML [1980]|TML [198000]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2991.12||||2991.12|418.76|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2991.12||||2991.12|1495|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UNICARE [2040]|UNICARE [204000]|2991.12||||2991.12|1495|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2991.12||||2991.12|1495|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WEB TPA [2115]|WEB TPA [211500]|2991.12||||2991.12|2063.87|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2991.12||||2991.12|329.84|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2991.12||||2991.12|659.69|2646|329.84
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WORKER'S COMP [2125]|TML WC [212537]|2991.12||||2991.12|1495|2646|329.84
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AARP [1000]|AARP [100000]|2991.12||||2991.12|1495|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AETNA [1015]|AETNA [101529]|2991.12||||2991.12|1346|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AMBETTER [2930]|AMBETTER [293000]|2991.12||||2991.12|497.14|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2991.12||||2991.12|1495.56|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2991.12||||2991.12|1196.45|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2991.12||||2991.12|1196.45|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2991.12||||2991.12|1405.83|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2991.12||||2991.12|1226.36|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA [1260]|CIGNA PPO [126025]|2991.12||||2991.12|2991.12|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2991.12||||2991.12|1495|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2991.12||||2991.12|1495.56|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2991.12||||2991.12|1346|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2991.12||||2991.12|1346|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2991.12||||2991.12|0|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|Self-pay|Self-pay|2991.12||||2991.12|598.22|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|TML [1980]|TML [198000]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2991.12||||2991.12|418.76|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2991.12||||2991.12|1495|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UNICARE [2040]|UNICARE [204000]|2991.12||||2991.12|1495|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2991.12||||2991.12|1495|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WEB TPA [2115]|WEB TPA [211500]|2991.12||||2991.12|2063.87|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2991.12||||2991.12|473.47|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2991.12||||2991.12|946.93|2991.12|418.76
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WORKER'S COMP [2125]|TML WC [212537]|2991.12||||2991.12|1495|2991.12|418.76
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.35||||2.35|1.06|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.35||||2.35|1.18|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.35||||2.35|0.94|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.35||||2.35|0.94|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.35||||2.35|1.1|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.35||||2.35|0.96|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.35||||2.35|0.94|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.35||||2.35|1.18|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.35||||2.35|1.06|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.35||||2.35|1.06|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.35||||2.35|0.47|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.35||||2.35|0.33|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.35||||2.35|0|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.35||||2.35|1.62|1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.35||||2.35||1.62|0.33
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.35||||2.35|0|1.62|0.33
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.74|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.65||||1.65|0.83|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.66|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.66|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|0.78|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.65||||1.65|0.68|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.65||||1.65|0.66|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.65||||1.65|0.83|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.74|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.74|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.33|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.23|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65|0|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.65||||1.65|1.14|1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.23
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.65||||1.65|0|1.14|0.23
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.98||||1.98|0.89|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.98||||1.98|0.99|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.98||||1.98|0.79|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.98||||1.98|0.79|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.98||||1.98|0.93|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.98||||1.98|0.81|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.98||||1.98|0.79|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.98||||1.98|0.99|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.98||||1.98|0.89|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.98||||1.98|0.89|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.98||||1.98|0.4|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.98||||1.98|0.28|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.98||||1.98|0|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.98||||1.98|1.37|1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.98||||1.98||1.37|0.28
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.98||||1.98|0|1.37|0.28
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.22||||2.22|1|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.22||||2.22|1.11|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.22||||2.22|0.89|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.22||||2.22|0.89|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.22||||2.22|1.04|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.22||||2.22|0.91|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.22||||2.22|0.89|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.22||||2.22|1.11|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.22||||2.22|1|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.22||||2.22|1|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.22||||2.22|0.44|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.22||||2.22|0.31|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.22||||2.22|0|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.22||||2.22|1.53|1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.22||||2.22||1.53|0.31
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.22||||2.22|0|1.53|0.31
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.86||||8.86|3.99|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.86||||8.86|4.43|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.86||||8.86|3.54|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.86||||8.86|3.54|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.86||||8.86|4.16|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.86||||8.86|3.63|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.86||||8.86|3.54|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.86||||8.86|4.43|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.86||||8.86|3.99|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.86||||8.86|3.99|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.86||||8.86|1.77|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.86||||8.86|1.24|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.86||||8.86|0|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.86||||8.86|6.11|6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.86||||8.86||6.11|1.24
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.86||||8.86|0|6.11|1.24
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.98||||0.98|0.44|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.98||||0.98|0.49|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.98||||0.98|0.39|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.98||||0.98|0.39|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.98||||0.98|0.46|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.98||||0.98|0.4|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.98||||0.98|0.39|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.98||||0.98|0.49|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.98||||0.98|0.44|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.98||||0.98|0.44|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.98||||0.98|0.2|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.98||||0.98|0.14|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.98||||0.98|0|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.98||||0.98|0.68|0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.98||||0.98||0.68|0.14
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.98||||0.98|0|0.68|0.14
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.66||||0.66|0.3|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.66||||0.66|0.33|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.26|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.26|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.31|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.66||||0.66|0.27|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.66||||0.66|0.26|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.66||||0.66|0.33|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0.3|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0.3|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.66||||0.66|0.13|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.09|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66|0|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.66||||0.66|0.46|0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.66||||0.66||0.46|0.09
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.66||||0.66|0|0.46|0.09
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AARP [1000]|AARP [100000]|2031.84||||2031.84|327|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AETNA [1015]|AETNA [101529]|2031.84||||2031.84|914.33|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AMBETTER [2930]|AMBETTER [293000]|2031.84||||2031.84|132.87|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2031.84||||2031.84|1015.92|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2031.84||||2031.84|812.74|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2031.84||||2031.84|812.74|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2031.84||||2031.84|954.96|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2031.84||||2031.84|833.05|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA [1260]|CIGNA PPO [126025]|2031.84||||2031.84|812.74|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2031.84||||2031.84|327|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2031.84||||2031.84|1015.92|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2031.84||||2031.84|914.33|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2031.84||||2031.84|914.33|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2031.84||||2031.84|0|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|Self-pay|Self-pay|2031.84||||2031.84|406.37|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|TML [1980]|TML [198000]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2031.84||||2031.84|284.46|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2031.84||||2031.84|327|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UNICARE [2040]|UNICARE [204000]|2031.84||||2031.84|327|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2031.84||||2031.84|327|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WEB TPA [2115]|WEB TPA [211500]|2031.84||||2031.84|1401.97|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2031.84||||2031.84|126.54|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2031.84||||2031.84|253.09|1401.97|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WORKER'S COMP [2125]|TML WC [212537]|2031.84||||2031.84|327|1401.97|126.54
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AARP [1000]|AARP [100000]|2031.84||||2031.84|327|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AETNA [1015]|AETNA [101529]|2031.84||||2031.84|914.33|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AMBETTER [2930]|AMBETTER [293000]|2031.84||||2031.84|251.79|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2031.84||||2031.84|1015.92|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2031.84||||2031.84|812.74|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2031.84||||2031.84|812.74|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2031.84||||2031.84|954.96|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2031.84||||2031.84|833.05|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA [1260]|CIGNA PPO [126025]|2031.84||||2031.84|812.74|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2031.84||||2031.84|327|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2031.84||||2031.84|1015.92|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2031.84||||2031.84|914.33|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2031.84||||2031.84|914.33|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2031.84||||2031.84|0|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|Self-pay|Self-pay|2031.84||||2031.84|406.37|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|TML [1980]|TML [198000]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2031.84||||2031.84|284.46|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2031.84||||2031.84|327|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UNICARE [2040]|UNICARE [204000]|2031.84||||2031.84|327|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2031.84||||2031.84|327|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WEB TPA [2115]|WEB TPA [211500]|2031.84||||2031.84|1401.97|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2031.84||||2031.84|239.8|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2031.84||||2031.84|479.61|1401.97|239.8
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WORKER'S COMP [2125]|TML WC [212537]|2031.84||||2031.84|327|1401.97|239.8
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AARP [1000]|AARP [100000]|3042.72||||3042.72|327|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AETNA [1015]|AETNA [101529]|3042.72||||3042.72|1369.22|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AMBETTER [2930]|AMBETTER [293000]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3042.72||||3042.72|1521.36|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3042.72||||3042.72|1217.09|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3042.72||||3042.72|1217.09|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3042.72||||3042.72|1430.08|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3042.72||||3042.72|1247.52|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA [1260]|CIGNA PPO [126025]|3042.72||||3042.72|1217.09|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3042.72||||3042.72|327|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3042.72||||3042.72|1521.36|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3042.72||||3042.72|1369.22|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3042.72||||3042.72|1369.22|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3042.72||||3042.72|0|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|Self-pay|Self-pay|3042.72||||3042.72|608.54|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|TML [1980]|TML [198000]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3042.72||||3042.72|425.98|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3042.72||||3042.72|327|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UNICARE [2040]|UNICARE [204000]|3042.72||||3042.72|327|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3042.72||||3042.72|327|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WEB TPA [2115]|WEB TPA [211500]|3042.72||||3042.72|2099.48|2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3042.72||||3042.72||2099.48|327
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WORKER'S COMP [2125]|TML WC [212537]|3042.72||||3042.72|327|2099.48|327
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AARP [1000]|AARP [100000]|323.5||||323.5|323.5|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA [1015]|AETNA [101529]|323.5||||323.5|145.58|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMBETTER [2930]|AMBETTER [293000]|323.5||||323.5|2.31|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|323.5||||323.5|161.75|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|323.5||||323.5|129.4|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|323.5||||323.5|129.4|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|323.5||||323.5|152.05|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|323.5||||323.5|132.64|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA [1260]|CIGNA PPO [126025]|323.5||||323.5|129.4|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|323.5||||323.5|323.5|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|323.5||||323.5|161.75|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323.5||||323.5|145.58|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|323.5||||323.5|145.58|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|323.5||||323.5|0|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|Self-pay|Self-pay|323.5||||323.5|64.7|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|TML [1980]|TML [198000]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|323.5||||323.5|45.29|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|323.5||||323.5|323.5|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNICARE [2040]|UNICARE [204000]|323.5||||323.5|323.5|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|323.5||||323.5|323.5|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WEB TPA [2115]|WEB TPA [211500]|323.5||||323.5|223.22|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|323.5||||323.5|2.2|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|323.5||||323.5|4.56|323.5|2.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WORKER'S COMP [2125]|TML WC [212537]|323.5||||323.5|323.5|323.5|2.2
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AARP [1000]|AARP [100000]|51.75||||51.75|51.75|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA [1015]|AETNA [101529]|51.75||||51.75|23.29|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMBETTER [2930]|AMBETTER [293000]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.75||||51.75|25.88|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.75||||51.75|20.7|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.75||||51.75|20.7|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.75||||51.75|24.32|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.75||||51.75|21.22|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA [1260]|CIGNA PPO [126025]|51.75||||51.75|20.7|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.75||||51.75|51.75|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.75||||51.75|25.88|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.75||||51.75|23.29|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.75||||51.75|23.29|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.75||||51.75|0|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|Self-pay|Self-pay|51.75||||51.75|10.35|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|TML [1980]|TML [198000]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.75||||51.75|7.25|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.75||||51.75|51.75|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNICARE [2040]|UNICARE [204000]|51.75||||51.75|51.75|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.75||||51.75|51.75|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WEB TPA [2115]|WEB TPA [211500]|51.75||||51.75|35.71|51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.75||||51.75||51.75|7.25
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WORKER'S COMP [2125]|TML WC [212537]|51.75||||51.75|51.75|51.75|7.25
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AARP [1000]|AARP [100000]|2355.84||||2355.84|327|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA [1015]|AETNA [101529]|2355.84||||2355.84|1060.13|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMBETTER [2930]|AMBETTER [293000]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2355.84||||2355.84|1177.92|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2355.84||||2355.84|942.34|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2355.84||||2355.84|942.34|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2355.84||||2355.84|1107.24|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2355.84||||2355.84|965.89|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA [1260]|CIGNA PPO [126025]|2355.84||||2355.84|942.34|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2355.84||||2355.84|327|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2355.84||||2355.84|1177.92|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2355.84||||2355.84|1060.13|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2355.84||||2355.84|1060.13|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2355.84||||2355.84|0|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|Self-pay|Self-pay|2355.84||||2355.84|471.17|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|TML [1980]|TML [198000]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2355.84||||2355.84|329.82|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2355.84||||2355.84|327|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNICARE [2040]|UNICARE [204000]|2355.84||||2355.84|327|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2355.84||||2355.84|327|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WEB TPA [2115]|WEB TPA [211500]|2355.84||||2355.84|1625.53|1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2355.84||||2355.84||1625.53|327
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WORKER'S COMP [2125]|TML WC [212537]|2355.84||||2355.84|327|1625.53|327
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AARP [1000]|AARP [100000]|404||||404|327|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA [1015]|AETNA [101529]|404||||404|181.8|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMBETTER [2930]|AMBETTER [293000]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|404||||404|202|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|404||||404|161.6|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|404||||404|161.6|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|404||||404|189.88|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|404||||404|165.64|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA [1260]|CIGNA PPO [126025]|404||||404|161.6|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|404||||404|327|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|404||||404|202|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|404||||404|181.8|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|404||||404|181.8|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|404||||404|0|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|Self-pay|Self-pay|404||||404|80.8|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|TML [1980]|TML [198000]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|404||||404|56.56|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|404||||404|327|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNICARE [2040]|UNICARE [204000]|404||||404|327|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|404||||404|327|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WEB TPA [2115]|WEB TPA [211500]|404||||404|278.76|327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|404||||404||327|56.56
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WORKER'S COMP [2125]|TML WC [212537]|404||||404|327|327|56.56
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AARP [1000]|AARP [100000]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AETNA [1015]|AETNA [101529]|576.84||||576.84|259.58|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMBETTER [2930]|AMBETTER [293000]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|576.84||||576.84|288.42|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|576.84||||576.84|230.74|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|576.84||||576.84|230.74|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|576.84||||576.84|271.11|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|576.84||||576.84|236.5|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|576.84||||576.84|230.74|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|576.84||||576.84|288.42|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|576.84||||576.84|259.58|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|576.84||||576.84|259.58|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|Self-pay|Self-pay|576.84||||576.84|115.37|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|TML [1980]|TML [198000]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|576.84||||576.84|80.76|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNICARE [2040]|UNICARE [204000]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|576.84||||576.84|0|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WEB TPA [2115]|WEB TPA [211500]|576.84||||576.84|398.02|398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|576.84||||576.84||398.02|80.76
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|576.84||||576.84|0|398.02|80.76
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|64.02||||64.02|28.81|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.02||||64.02|32.01|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.02||||64.02|25.61|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.02||||64.02|25.61|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.02||||64.02|30.09|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.02||||64.02|26.25|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|64.02||||64.02|25.61|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.02||||64.02|32.01|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.02||||64.02|28.81|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.02||||64.02|28.81|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|64.02||||64.02|12.8|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TML [1980]|TML [198000]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.02||||64.02|8.96|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.02||||64.02|0|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|64.02||||64.02|44.17|44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.02||||64.02||44.17|8.96
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|64.02||||64.02|0|44.17|8.96
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AARP [1000]|AARP [100000]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AETNA [1015]|AETNA [101529]|23.45||||23.45|10.55|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMBETTER [2930]|AMBETTER [293000]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.45||||23.45|11.73|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.45||||23.45|9.38|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.45||||23.45|9.38|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.45||||23.45|11.02|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.45||||23.45|9.61|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA [1260]|CIGNA PPO [126025]|23.45||||23.45|9.38|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.45||||23.45|11.73|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.45||||23.45|10.55|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.45||||23.45|10.55|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|Self-pay|Self-pay|23.45||||23.45|4.69|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|TML [1980]|TML [198000]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.45||||23.45|3.28|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UNICARE [2040]|UNICARE [204000]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.45||||23.45|0|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WEB TPA [2115]|WEB TPA [211500]|23.45||||23.45|16.18|16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.45||||23.45||16.18|3.28
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WORKER'S COMP [2125]|TML WC [212537]|23.45||||23.45|0|16.18|3.28
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|178.2||||178.2|80.19|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|178.2||||178.2|89.1|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178.2||||178.2|71.28|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178.2||||178.2|71.28|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178.2||||178.2|83.75|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|178.2||||178.2|73.06|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|178.2||||178.2|71.28|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|178.2||||178.2|89.1|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178.2||||178.2|80.19|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178.2||||178.2|80.19|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|178.2||||178.2|35.64|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178.2||||178.2|24.95|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178.2||||178.2|0|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|178.2||||178.2|122.96|122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|178.2||||178.2||122.96|24.95
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|178.2||||178.2|0|122.96|24.95
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|31.29||||31.29|14.08|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|31.29||||31.29|15.65|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.29||||31.29|12.52|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.29||||31.29|12.52|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.29||||31.29|14.71|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|31.29||||31.29|12.83|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|31.29||||31.29|12.52|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|31.29||||31.29|15.65|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.29||||31.29|14.08|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.29||||31.29|14.08|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|31.29||||31.29|6.26|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.29||||31.29|4.38|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.29||||31.29|0|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|31.29||||31.29|21.59|21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.29||||31.29||21.59|4.38
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|31.29||||31.29|0|21.59|4.38
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AARP [1000]|AARP [100000]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AARP [1000]|AARP [100000]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AETNA [1015]|AETNA [101529]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AETNA [1015]|AETNA [101529]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMBETTER [2930]|AMBETTER [293000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMBETTER [2930]|AMBETTER [293000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.18||||37.18|18.59|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.18||||37.18|18.59|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.18||||37.18|17.47|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.18||||37.18|17.47|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.18||||37.18|15.24|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.18||||37.18|15.24|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA [1260]|CIGNA PPO [126025]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|CIGNA [1260]|CIGNA PPO [126025]|37.18||||37.18|14.87|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.18||||37.18|18.59|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.18||||37.18|18.59|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.18||||37.18|16.73|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|Self-pay|Self-pay|37.18||||37.18|7.44|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|Self-pay|Self-pay|37.18||||37.18|7.44|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|TML [1980]|TML [198000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|TML [1980]|TML [198000]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.18||||37.18|5.21|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.18||||37.18|5.21|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UNICARE [2040]|UNICARE [204000]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UNICARE [2040]|UNICARE [204000]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WEB TPA [2115]|WEB TPA [211500]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WEB TPA [2115]|WEB TPA [211500]|37.18||||37.18|25.65|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.18||||37.18||25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WORKER'S COMP [2125]|TML WC [212537]|37.18||||37.18|0|25.65|5.21
4749|ERX|0250 - PHARMACY-GENERAL|MANNITOL 20 % INTRAVENOUS SOLUTION|32 mL|WORKER'S COMP [2125]|TML WC [212537]|37.18||||37.18|0|25.65|5.21
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AARP [1000]|AARP [100000]|29399.77||||29399.77|4671|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AETNA [1015]|AETNA [101529]|29399.77||||29399.77|13229.9|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AMBETTER [2930]|AMBETTER [293000]|29399.77||||29399.77|2760.33|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29399.77||||29399.77|14699.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29399.77||||29399.77|11759.91|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29399.77||||29399.77|11759.91|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29399.77||||29399.77|13817.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29399.77||||29399.77|12053.91|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|CIGNA [1260]|CIGNA PPO [126025]|29399.77||||29399.77|11759.91|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29399.77||||29399.77|4671|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29399.77||||29399.77|14699.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29399.77||||29399.77|13229.9|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29399.77||||29399.77|13229.9|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29399.77||||29399.77|0|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|Self-pay|Self-pay|29399.77||||29399.77|5879.95|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|TML [1980]|TML [198000]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29399.77||||29399.77|4115.97|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29399.77||||29399.77|4671|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|UNICARE [2040]|UNICARE [204000]|29399.77||||29399.77|4671|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29399.77||||29399.77|4671|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|WEB TPA [2115]|WEB TPA [211500]|29399.77||||29399.77|18815.85|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29399.77||||29399.77|2628.89|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29399.77||||29399.77|5257.78|18815.85|2628.89
48193458|EAP|0481 - CARDIOLOGY-CARDIAC CATH LAB|HC LT HRT CATH COR ANG LTVENT INJS&I|1|WORKER'S COMP [2125]|TML WC [212537]|29399.77||||29399.77|4671|18815.85|2628.89
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AARP [1000]|AARP [100000]|3548||||3548|886|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3548||||3548|254.37|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AETNA [1015]|AETNA [101529]|3548||||3548|1596.6|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AMBETTER [2930]|AMBETTER [293000]|3548||||3548|251.79|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3548||||3548|33.4|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3548||||3548|1774|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3548||||3548|33.4|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3548||||3548|1419.2|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3548||||3548|1419.2|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3548||||3548|1667.56|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3548||||3548|1454.68|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3548||||3548|33.4|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|3548||||3548|1419.2|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3548||||3548|886|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3548||||3548|1774|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3548||||3548|239.8|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3548||||3548|1596.6|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3548||||3548|33.4|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3548||||3548|1596.6|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3548||||3548|0|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|Self-pay|Self-pay|3548||||3548|709.6|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|TML [1980]|TML [198000]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3548||||3548|496.72|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3548||||3548|886|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UNICARE [2040]|UNICARE [204000]|3548||||3548|886|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3548||||3548|886|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WEB TPA [2115]|WEB TPA [211500]|3548||||3548|2448.12|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3548||||3548|33.4|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3548||||3548|63.54|2448.12|33.4
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|3548||||3548|886|2448.12|33.4
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AARP [1000]|AARP [100000]|5398.73||||5398.73|374|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5398.73||||5398.73|130.7|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA [1015]|AETNA [101529]|5398.73||||5398.73|2429.43|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|5398.73||||5398.73|137.24|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5398.73||||5398.73|130.7|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5398.73||||5398.73|2699.37|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5398.73||||5398.73|464.48|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5398.73||||5398.73|2159.49|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5398.73||||5398.73|2159.49|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5398.73||||5398.73|2537.4|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5398.73||||5398.73|2213.48|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5398.73||||5398.73|130.7|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|5398.73||||5398.73|2159.49|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5398.73||||5398.73|374|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5398.73||||5398.73|2699.37|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5398.73||||5398.73|501.35|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5398.73||||5398.73|2429.43|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5398.73||||5398.73|130.7|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5398.73||||5398.73|2429.43|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5398.73||||5398.73|0|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|Self-pay|Self-pay|5398.73||||5398.73|1079.75|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|TML [1980]|TML [198000]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5398.73||||5398.73|755.82|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5398.73||||5398.73|374|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNICARE [2040]|UNICARE [204000]|5398.73||||5398.73|374|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5398.73||||5398.73|374|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|5398.73||||5398.73|3725.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5398.73||||5398.73|130.7|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5398.73||||5398.73|246.12|3725.12|130.7
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|5398.73||||5398.73|374|3725.12|130.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AARP [1000]|AARP [100000]|1378||||1378|374|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA [1015]|AETNA [101529]|1378||||1378|620.1|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMBETTER [2930]|AMBETTER [293000]|1378||||1378|232.42|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1378||||1378|689|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1378||||1378|551.2|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1378||||1378|551.2|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1378||||1378|647.66|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1378||||1378|564.98|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA [1260]|CIGNA PPO [126025]|1378||||1378|551.2|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1378||||1378|374|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1378||||1378|689|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1378||||1378|620.1|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1378||||1378|620.1|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1378||||1378|0|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|Self-pay|Self-pay|1378||||1378|275.6|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|TML [1980]|TML [198000]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1378||||1378|92.89|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1378||||1378|374|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNICARE [2040]|UNICARE [204000]|1378||||1378|374|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1378||||1378|374|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WEB TPA [2115]|WEB TPA [211500]|1378||||1378|950.82|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1378||||1378|221.36|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1378||||1378|442.71|950.82|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WORKER'S COMP [2125]|TML WC [212537]|1378||||1378|374|950.82|92.89
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AARP [1000]|AARP [100000]|1660||||1660|374|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA [1015]|AETNA [101529]|1660||||1660|747|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMBETTER [2930]|AMBETTER [293000]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1660||||1660|830|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1660||||1660|664|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1660||||1660|664|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1660||||1660|780.2|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1660||||1660|680.6|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA [1260]|CIGNA PPO [126025]|1660||||1660|664|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1660||||1660|374|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1660||||1660|830|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1660||||1660|747|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1660||||1660|747|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1660||||1660|0|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|Self-pay|Self-pay|1660||||1660|332|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|TML [1980]|TML [198000]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1660||||1660|232.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1660||||1660|374|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNICARE [2040]|UNICARE [204000]|1660||||1660|374|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1660||||1660|374|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WEB TPA [2115]|WEB TPA [211500]|1660||||1660|1145.4|1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1660||||1660||1145.4|232.4
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WORKER'S COMP [2125]|TML WC [212537]|1660||||1660|374|1145.4|232.4
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.88||||1.88|0.85|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.88||||1.88|0.94|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.88||||1.88|0.75|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.88||||1.88|0.75|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.88||||1.88|0.88|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.88||||1.88|0.77|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.88||||1.88|0.75|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.88||||1.88|0.94|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.88||||1.88|0.85|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.88||||1.88|0.85|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.88||||1.88|0.38|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.88||||1.88|0.26|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.88||||1.88|0|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.88||||1.88|1.3|1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.88||||1.88||1.3|0.26
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.88||||1.88|0|1.3|0.26
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.7|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.55||||1.55|0.78|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0.62|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.62|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.73|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.55||||1.55|0.64|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.55||||1.55|0.62|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.55||||1.55|0.78|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.7|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.7|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|Self-pay|Self-pay|1.55||||1.55|0.31|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.22|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55|0|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.55||||1.55|1.07|1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.07|0.22
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.55||||1.55|0|1.07|0.22
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|23.84||||23.84|10.73|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.84||||23.84|11.92|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.84||||23.84|9.54|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.84||||23.84|9.54|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.84||||23.84|11.2|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.84||||23.84|9.77|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|23.84||||23.84|9.54|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.84||||23.84|11.92|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.84||||23.84|10.73|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.84||||23.84|10.73|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|23.84||||23.84|4.77|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.84||||23.84|3.34|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.84||||23.84|0|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|23.84||||23.84|16.45|16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.84||||23.84||16.45|3.34
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|23.84||||23.84|0|16.45|3.34
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.68|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.52||||1.52|0.76|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.61|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.61|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.71|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.52||||1.52|0.62|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.52||||1.52|0.61|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.52||||1.52|0.76|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.68|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.68|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.3|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.21|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52|0|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.52||||1.52|1.05|1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.21
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.52||||1.52|0|1.05|0.21
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.98||||21.98|9.89|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.98||||21.98|10.99|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.98||||21.98|8.79|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.98||||21.98|8.79|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.98||||21.98|10.33|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.98||||21.98|9.01|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.98||||21.98|8.79|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.98||||21.98|10.99|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.98||||21.98|9.89|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.98||||21.98|9.89|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|21.98||||21.98|4.4|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.98||||21.98|3.08|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.98||||21.98|0|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.98||||21.98|15.17|15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.98||||21.98||15.17|3.08
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.98||||21.98|0|15.17|3.08
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|22.06||||22.06|9.93|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.06||||22.06|11.03|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.06||||22.06|8.82|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.06||||22.06|8.82|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.06||||22.06|10.37|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.06||||22.06|9.04|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|22.06||||22.06|8.82|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.06||||22.06|11.03|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.06||||22.06|9.93|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.06||||22.06|9.93|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|22.06||||22.06|4.41|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.06||||22.06|3.09|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.06||||22.06|0|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|22.06||||22.06|15.22|15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.06||||22.06||15.22|3.09
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|22.06||||22.06|0|15.22|3.09
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AARP [1000]|AARP [100000]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AETNA [1015]|AETNA [101529]|608.13||||608.13|273.66|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|608.13||||608.13|304.07|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|608.13||||608.13|243.25|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|608.13||||608.13|243.25|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|608.13||||608.13|285.82|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|608.13||||608.13|249.33|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|608.13||||608.13|243.25|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|608.13||||608.13|304.07|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|608.13||||608.13|273.66|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|608.13||||608.13|273.66|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|Self-pay|Self-pay|608.13||||608.13|121.63|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|TML [1980]|TML [198000]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|608.13||||608.13|85.14|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|UNICARE [2040]|UNICARE [204000]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|608.13||||608.13|0|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|608.13||||608.13|419.61|419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|608.13||||608.13||419.61|85.14
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|608.13||||608.13|0|419.61|85.14
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|14.74||||14.74|6.63|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.74||||14.74|7.37|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.74||||14.74|5.9|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.74||||14.74|5.9|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.74||||14.74|6.93|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.74||||14.74|6.04|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.74||||14.74|5.9|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.74||||14.74|7.37|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.74||||14.74|6.63|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.74||||14.74|6.63|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|14.74||||14.74|2.95|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.74||||14.74|2.06|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.74||||14.74|0|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.74||||14.74|10.17|10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.74||||14.74||10.17|2.06
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.74||||14.74|0|10.17|2.06
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.92||||7.92|3.56|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.92||||7.92|3.96|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.92||||7.92|3.17|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.92||||7.92|3.17|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.92||||7.92|3.72|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.92||||7.92|3.25|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.92||||7.92|3.17|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.92||||7.92|3.96|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.92||||7.92|3.56|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.92||||7.92|3.56|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|Self-pay|Self-pay|7.92||||7.92|1.58|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.92||||7.92|1.11|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.92||||7.92|0|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.92||||7.92|5.46|5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.92||||7.92||5.46|1.11
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.92||||7.92|0|5.46|1.11
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|35.58||||35.58|16.01|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|35.58||||35.58|17.79|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.58||||35.58|14.23|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.58||||35.58|14.23|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.58||||35.58|16.72|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|35.58||||35.58|14.59|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|35.58||||35.58|14.23|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|35.58||||35.58|17.79|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.58||||35.58|16.01|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.58||||35.58|16.01|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|35.58||||35.58|7.12|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.58||||35.58|4.98|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.58||||35.58|0|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|35.58||||35.58|24.55|24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.58||||35.58||24.55|4.98
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|35.58||||35.58|0|24.55|4.98
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.02||||1.02|0.46|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.02||||1.02|0.51|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.02||||1.02|0.41|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.02||||1.02|0.41|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.02||||1.02|0.48|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.02||||1.02|0.42|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.02||||1.02|0.41|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.02||||1.02|0.51|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.02||||1.02|0.46|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.02||||1.02|0.46|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.02||||1.02|0.2|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.02||||1.02|0.14|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.02||||1.02|0|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.02||||1.02|0.7|0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.02||||1.02||0.7|0.14
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.02||||1.02|0|0.7|0.14
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|19.8||||19.8|8.91|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.8||||19.8|9.9|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.8||||19.8|7.92|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.8||||19.8|7.92|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.8||||19.8|9.31|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.8||||19.8|8.12|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|19.8||||19.8|7.92|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.8||||19.8|9.9|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.8||||19.8|8.91|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.8||||19.8|8.91|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|19.8||||19.8|3.96|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.8||||19.8|2.77|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.8||||19.8|0|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|19.8||||19.8|13.66|13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.8||||19.8||13.66|2.77
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|19.8||||19.8|0|13.66|2.77
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AARP [1000]|AARP [100000]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA [1015]|AETNA [101529]|5.35||||5.35|2.41|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMBETTER [2930]|AMBETTER [293000]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.35||||5.35|2.68|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.35||||5.35|2.14|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.35||||5.35|2.14|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.35||||5.35|2.51|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.35||||5.35|2.19|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA PPO [126025]|5.35||||5.35|2.14|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.35||||5.35|2.68|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.35||||5.35|2.41|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.35||||5.35|2.41|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|Self-pay|Self-pay|5.35||||5.35|1.07|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|TML [1980]|TML [198000]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.35||||5.35|0.75|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNICARE [2040]|UNICARE [204000]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.35||||5.35|0|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WEB TPA [2115]|WEB TPA [211500]|5.35||||5.35|3.69|3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.35||||5.35||3.69|0.75
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WORKER'S COMP [2125]|TML WC [212537]|5.35||||5.35|0|3.69|0.75
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.5||||3.5|1.58|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.5||||3.5|1.75|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.5||||3.5|1.4|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.5||||3.5|1.4|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.5||||3.5|1.65|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.5||||3.5|1.44|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|3.5||||3.5|1.4|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.5||||3.5|1.75|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.5||||3.5|1.58|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.5||||3.5|1.58|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.5||||3.5|0.7|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.5||||3.5|0.49|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.5||||3.5|0|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|3.5||||3.5|2.42|2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.5||||3.5||2.42|0.49
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|3.5||||3.5|0|2.42|0.49
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.47||||8.47|3.81|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.47||||8.47|4.24|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.47||||8.47|3.39|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.47||||8.47|3.39|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.47||||8.47|3.98|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.47||||8.47|3.47|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.47||||8.47|3.39|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.47||||8.47|4.24|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.47||||8.47|3.81|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.47||||8.47|3.81|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|8.47||||8.47|1.69|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.47||||8.47|1.19|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.47||||8.47|0|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.47||||8.47|5.84|5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.47||||8.47||5.84|1.19
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.47||||8.47|0|5.84|1.19
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.78||||2.78|1.25|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.78||||2.78|1.39|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.78||||2.78|1.11|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.78||||2.78|1.11|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.78||||2.78|1.31|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.78||||2.78|1.14|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.78||||2.78|1.11|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.78||||2.78|1.39|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.78||||2.78|1.25|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.78||||2.78|1.25|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.78||||2.78|0.56|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.78||||2.78|0.39|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.78||||2.78|0|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.78||||2.78|1.92|1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.78||||2.78||1.92|0.39
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.78||||2.78|0|1.92|0.39
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AARP [1000]|AARP [100000]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.01||||10.01|4.5|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.01||||10.01|5.01|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.01||||10.01|4|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.01||||10.01|4|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.01||||10.01|4.7|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.01||||10.01|4.1|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.01||||10.01|4|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.01||||10.01|5.01|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.01||||10.01|4.5|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.01||||10.01|4.5|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|Self-pay|Self-pay|10.01||||10.01|2|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|TML [1980]|TML [198000]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.01||||10.01|1.4|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.01||||10.01|0|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.01||||10.01|6.91|6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.01||||10.01||6.91|1.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.01||||10.01|0|6.91|1.4
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|151.8||||151.8|68.31|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|151.8||||151.8|75.9|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|151.8||||151.8|60.72|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|151.8||||151.8|60.72|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|151.8||||151.8|71.35|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|151.8||||151.8|62.24|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|151.8||||151.8|60.72|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|151.8||||151.8|75.9|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|151.8||||151.8|68.31|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|151.8||||151.8|68.31|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|151.8||||151.8|30.36|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TML [1980]|TML [198000]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|151.8||||151.8|21.25|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|151.8||||151.8|0|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|151.8||||151.8|104.74|104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|151.8||||151.8||104.74|21.25
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|151.8||||151.8|0|104.74|21.25
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AARP [1000]|AARP [100000]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA [1015]|AETNA [101529]|286.44||||286.44|128.9|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMBETTER [2930]|AMBETTER [293000]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|286.44||||286.44|143.22|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|286.44||||286.44|114.58|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|286.44||||286.44|114.58|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|286.44||||286.44|134.63|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|286.44||||286.44|117.44|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA [1260]|CIGNA PPO [126025]|286.44||||286.44|114.58|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|286.44||||286.44|143.22|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|286.44||||286.44|128.9|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|286.44||||286.44|128.9|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|Self-pay|Self-pay|286.44||||286.44|57.29|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|TML [1980]|TML [198000]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|286.44||||286.44|40.1|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNICARE [2040]|UNICARE [204000]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|286.44||||286.44|0|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WEB TPA [2115]|WEB TPA [211500]|286.44||||286.44|197.64|197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|286.44||||286.44||197.64|40.1
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WORKER'S COMP [2125]|TML WC [212537]|286.44||||286.44|0|197.64|40.1
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|132||||132|59.4|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|66|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|52.8|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|52.8|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|62.04|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|54.12|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|66|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|59.4|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|59.4|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|132||||132|26.4|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|18.48|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|0|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132||91.08|18.48
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|132||||132|0|91.08|18.48
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.88||||2.88|1.3|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.88||||2.88|1.44|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.88||||2.88|1.15|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.88||||2.88|1.15|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.88||||2.88|1.35|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.88||||2.88|1.18|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.88||||2.88|1.15|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.88||||2.88|1.44|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.88||||2.88|1.3|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.88||||2.88|1.3|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.88||||2.88|0.58|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.88||||2.88|0.4|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.88||||2.88|0|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.88||||2.88|1.99|1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.88||||2.88||1.99|0.4
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.88||||2.88|0|1.99|0.4
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.44||||13.44|6.05|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.44||||13.44|6.72|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.44||||13.44|5.38|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.44||||13.44|5.38|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.44||||13.44|6.32|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.44||||13.44|5.51|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.44||||13.44|5.38|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.44||||13.44|6.72|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.44||||13.44|6.05|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.44||||13.44|6.05|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|13.44||||13.44|2.69|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.44||||13.44|1.88|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.44||||13.44|0|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.44||||13.44|9.27|9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.44||||13.44||9.27|1.88
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.44||||13.44|0|9.27|1.88
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AARP [1000]|AARP [100000]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|673.86||||673.86|303.24|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AMBETTER [2930]|AMBETTER [293000]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|673.86||||673.86|336.93|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|673.86||||673.86|269.54|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|673.86||||673.86|269.54|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|673.86||||673.86|316.71|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|673.86||||673.86|276.28|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA PPO [126025]|673.86||||673.86|269.54|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|673.86||||673.86|336.93|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|673.86||||673.86|303.24|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|673.86||||673.86|303.24|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|Self-pay|Self-pay|673.86||||673.86|134.77|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|TML [1980]|TML [198000]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|673.86||||673.86|94.34|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UNICARE [2040]|UNICARE [204000]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|673.86||||673.86|0|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WEB TPA [2115]|WEB TPA [211500]|673.86||||673.86|464.96|464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|673.86||||673.86||464.96|94.34
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TML WC [212537]|673.86||||673.86|0|464.96|94.34
5510001|EAP||HH RN INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AARP [1000]|AARP [100000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA [1015]|AETNA [101529]|||||127.81|57.51|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|51.12|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|51.12|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|60.07|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|52.4|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|57.51|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|57.51|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|Self-pay|Self-pay|||||127.81|25.56|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|TML [1980]|TML [198000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||60.07|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|60.07|25.56
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.27|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.59||||0.59|0.3|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.24|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.24|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.28|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.59||||0.59|0.24|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.59||||0.59|0.24|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.59||||0.59|0.3|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.27|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.27|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.12|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.08|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59|0|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.59||||0.59|0.41|0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||0.41|0.08
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.59||||0.59|0|0.41|0.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|36.3||||36.3|16.34|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.3||||36.3|18.15|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.3||||36.3|14.52|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.3||||36.3|14.52|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.3||||36.3|17.06|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.3||||36.3|14.88|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|36.3||||36.3|14.52|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.3||||36.3|18.15|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.3||||36.3|16.34|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.3||||36.3|16.34|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|36.3||||36.3|7.26|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.3||||36.3|5.08|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.3||||36.3|0|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|36.3||||36.3|25.05|25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.3||||36.3||25.05|5.08
5593|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|36.3||||36.3|0|25.05|5.08
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|9.9||||9.9|4.46|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.9||||9.9|4.95|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.9||||9.9|3.96|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.9||||9.9|3.96|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.9||||9.9|4.65|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.9||||9.9|4.06|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|9.9||||9.9|3.96|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.9||||9.9|4.95|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.9||||9.9|4.46|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.9||||9.9|4.46|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|9.9||||9.9|1.98|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.9||||9.9|1.39|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.9||||9.9|0|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|9.9||||9.9|6.83|6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.9||||9.9||6.83|1.39
5595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|9.9||||9.9|0|6.83|1.39
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|6.54||||6.54|2.94|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.54||||6.54|3.27|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.54||||6.54|2.62|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.54||||6.54|2.62|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.54||||6.54|3.07|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.54||||6.54|2.68|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.54||||6.54|2.62|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.54||||6.54|3.27|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.54||||6.54|2.94|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.54||||6.54|2.94|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|6.54||||6.54|1.31|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.54||||6.54|0.92|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.54||||6.54|0|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.54||||6.54|4.51|4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.54||||6.54||4.51|0.92
5600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.54||||6.54|0|4.51|0.92
5600001|EAP||HH MSW INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|92.19|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|81.95|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|81.95|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|96.29|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||204.87|84|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|92.19|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|92.19|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|Self-pay|Self-pay|||||204.87|40.97|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|TML [1980]|TML [198000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||204.87|0|96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87||96.29|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||204.87|0|96.29|40.97
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|7.53||||7.53|3.39|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.53||||7.53|3.77|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.53||||7.53|3.01|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.53||||7.53|3.01|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.53||||7.53|3.54|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.53||||7.53|3.09|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.53||||7.53|3.01|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.53||||7.53|3.77|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.53||||7.53|3.39|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.53||||7.53|3.39|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|7.53||||7.53|1.51|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.53||||7.53|1.05|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.53||||7.53|0|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.53||||7.53|5.2|5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.53||||7.53||5.2|1.05
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.53||||7.53|0|5.2|1.05
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.86||||10.86|4.89|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.86||||10.86|5.43|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.86||||10.86|4.34|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.86||||10.86|4.34|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.86||||10.86|5.1|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.86||||10.86|4.45|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.86||||10.86|4.34|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.86||||10.86|5.43|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.86||||10.86|4.89|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.86||||10.86|4.89|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|10.86||||10.86|2.17|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|TML [1980]|TML [198000]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.86||||10.86|1.52|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.86||||10.86|0|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.86||||10.86|7.49|7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.86||||10.86||7.49|1.52
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.86||||10.86|0|7.49|1.52
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AARP [1000]|AARP [100000]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA [1015]|AETNA [101529]|29.1||||29.1|13.1|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMBETTER [2930]|AMBETTER [293000]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.1||||29.1|14.55|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.1||||29.1|11.64|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.1||||29.1|11.64|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.1||||29.1|13.68|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.1||||29.1|11.93|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA [1260]|CIGNA PPO [126025]|29.1||||29.1|11.64|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.1||||29.1|14.55|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.1||||29.1|13.1|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.1||||29.1|13.1|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|Self-pay|Self-pay|29.1||||29.1|5.82|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|TML [1980]|TML [198000]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.1||||29.1|4.07|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNICARE [2040]|UNICARE [204000]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.1||||29.1|0|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WEB TPA [2115]|WEB TPA [211500]|29.1||||29.1|20.08|20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.1||||29.1||20.08|4.07
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WORKER'S COMP [2125]|TML WC [212537]|29.1||||29.1|0|20.08|4.07
5610001|EAP||HH MSW ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|92.19|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|81.95|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|81.95|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|96.29|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||204.87|84|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|92.19|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|92.19|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|Self-pay|Self-pay|||||204.87|40.97|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|TML [1980]|TML [198000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||204.87|0|96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87||96.29|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||204.87|0|96.29|40.97
5710001|EAP||HH HHA VISIT|1|AARP [1000]|AARP [100000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|AETNA [1015]|AETNA [101529]|||||57.88|26.05|27.2|11.58
5710001|EAP||HH HHA VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||57.88|23.15|27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||57.88|23.15|27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||57.88|27.2|27.2|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||57.88|23.73|27.2|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||57.88|26.05|27.2|11.58
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||57.88|26.05|27.2|11.58
5710001|EAP||HH HHA VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|Self-pay|Self-pay|||||57.88|11.58|27.2|11.58
5710001|EAP||HH HHA VISIT|1|TML [1980]|TML [198000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|UNICARE [2040]|UNICARE [204000]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||57.88|0|27.2|11.58
5710001|EAP||HH HHA VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||57.88||27.2|11.58
5710001|EAP||HH HHA VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||57.88|0|27.2|11.58
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|171.47||||171.47|77.16|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|171.47||||171.47|85.74|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171.47||||171.47|68.59|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171.47||||171.47|68.59|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171.47||||171.47|80.59|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|171.47||||171.47|70.3|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|171.47||||171.47|68.59|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|171.47||||171.47|85.74|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171.47||||171.47|77.16|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171.47||||171.47|77.16|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|Self-pay|Self-pay|171.47||||171.47|34.29|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|TML [1980]|TML [198000]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171.47||||171.47|24.01|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171.47||||171.47|0|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|171.47||||171.47|118.31|118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171.47||||171.47||118.31|24.01
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|171.47||||171.47|0|118.31|24.01
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|184.74||||184.74|83.13|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.74||||184.74|92.37|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184.74||||184.74|73.9|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184.74||||184.74|73.9|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184.74||||184.74|86.83|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.74||||184.74|75.74|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|184.74||||184.74|73.9|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.74||||184.74|92.37|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.74||||184.74|83.13|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.74||||184.74|83.13|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|Self-pay|Self-pay|184.74||||184.74|36.95|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184.74||||184.74|25.86|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184.74||||184.74|0|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|184.74||||184.74|127.47|127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184.74||||184.74||127.47|25.86
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|184.74||||184.74|0|127.47|25.86
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|11.09||||11.09|4.99|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.09||||11.09|5.55|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.09||||11.09|4.44|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.09||||11.09|4.44|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.09||||11.09|5.21|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.09||||11.09|4.55|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|11.09||||11.09|4.44|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.09||||11.09|5.55|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.09||||11.09|4.99|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.09||||11.09|4.99|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|11.09||||11.09|2.22|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.09||||11.09|1.55|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|11.09||||11.09|7.65|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.09||||11.09||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|11.09||||11.09|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|71.28|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|63.36|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|63.36|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|74.45|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|64.94|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|71.28|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|71.28|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|158.4||||158.4|31.68|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|22.18|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|0|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4||109.3|1.55
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|0|109.3|1.55
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|276.61||||276.61|124.47|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|276.61||||276.61|138.31|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|276.61||||276.61|110.64|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|276.61||||276.61|110.64|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|276.61||||276.61|130.01|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|276.61||||276.61|113.41|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|276.61||||276.61|110.64|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|276.61||||276.61|138.31|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|276.61||||276.61|124.47|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|276.61||||276.61|124.47|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|276.61||||276.61|55.32|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|276.61||||276.61|38.73|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|276.61||||276.61|0|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|276.61||||276.61|190.86|190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|276.61||||276.61||190.86|38.73
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|276.61||||276.61|0|190.86|38.73
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|205.92||||205.92|92.66|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205.92||||205.92|102.96|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205.92||||205.92|82.37|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205.92||||205.92|82.37|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205.92||||205.92|96.78|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205.92||||205.92|84.43|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|205.92||||205.92|82.37|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205.92||||205.92|102.96|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.92||||205.92|92.66|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.92||||205.92|92.66|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|205.92||||205.92|41.18|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205.92||||205.92|28.83|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205.92||||205.92|0|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|205.92||||205.92|142.08|142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205.92||||205.92||142.08|28.83
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|205.92||||205.92|0|142.08|28.83
5800001|EAP||HH INITIAL RT VISIT|1|AARP [1000]|AARP [100000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|AETNA [1015]|AETNA [101529]|||||150|67.5|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|60|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|60|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|70.5|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||150|61.5|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|67.5|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|67.5|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|Self-pay|Self-pay|||||150|30|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|TML [1980]|TML [198000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|UNICARE [2040]|UNICARE [204000]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||150|0|70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150||70.5|30
5800001|EAP||HH INITIAL RT VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||150|67.5|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|60|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|60|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|70.5|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||150|61.5|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|67.5|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|67.5|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|Self-pay|Self-pay|||||150|30|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||150|0|70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150||70.5|30
5810001|EAP||HH RT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||150|0|70.5|30
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|26.25||||26.25|11.81|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.25||||26.25|13.13|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.25||||26.25|10.5|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.25||||26.25|10.5|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.25||||26.25|12.34|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.25||||26.25|10.76|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|26.25||||26.25|10.5|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.25||||26.25|13.13|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.25||||26.25|11.81|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.25||||26.25|11.81|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|26.25||||26.25|5.25|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.25||||26.25|3.68|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.25||||26.25|0|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|26.25||||26.25|18.11|18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.25||||26.25||18.11|3.68
5930|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|26.25||||26.25|0|18.11|3.68
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|28.87||||28.87|12.99|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.87||||28.87|14.44|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.87||||28.87|11.55|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.87||||28.87|11.55|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.87||||28.87|13.57|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28.87||||28.87|11.84|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|28.87||||28.87|11.55|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.87||||28.87|14.44|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.87||||28.87|12.99|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.87||||28.87|12.99|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|Self-pay|Self-pay|28.87||||28.87|5.77|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.87||||28.87|4.04|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.87||||28.87|0|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|28.87||||28.87|19.92|19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.87||||28.87||19.92|4.04
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|28.87||||28.87|0|19.92|4.04
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.02||||6.02|2.71|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.02||||6.02|3.01|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.02||||6.02|2.41|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.02||||6.02|2.41|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.02||||6.02|2.83|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.02||||6.02|2.47|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.02||||6.02|2.41|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.02||||6.02|3.01|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.02||||6.02|2.71|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.02||||6.02|2.71|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.02||||6.02|1.2|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.02||||6.02|0.84|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.02||||6.02|0|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.02||||6.02|4.15|4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.02||||6.02||4.15|0.84
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.02||||6.02|0|4.15|0.84
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.36||||5.36|2.41|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.36||||5.36|2.68|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.36||||5.36|2.14|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.36||||5.36|2.14|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.36||||5.36|2.52|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.36||||5.36|2.2|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.36||||5.36|2.14|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.36||||5.36|2.68|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.36||||5.36|2.41|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.36||||5.36|2.41|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|Self-pay|Self-pay|5.36||||5.36|1.07|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.36||||5.36|0.75|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.36||||5.36|0|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.36||||5.36|3.7|3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.36||||5.36||3.7|0.75
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.36||||5.36|0|3.7|0.75
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AARP [1000]|AARP [100000]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA [1015]|AETNA [101529]|62.57||||62.57|28.16|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMBETTER [2930]|AMBETTER [293000]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62.57||||62.57|31.29|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.57||||62.57|25.03|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.57||||62.57|25.03|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.57||||62.57|29.41|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62.57||||62.57|25.65|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA PPO [126025]|62.57||||62.57|25.03|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62.57||||62.57|31.29|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.57||||62.57|28.16|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.57||||62.57|28.16|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|Self-pay|Self-pay|62.57||||62.57|12.51|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|TML [1980]|TML [198000]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.57||||62.57|8.76|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNICARE [2040]|UNICARE [204000]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WEB TPA [2115]|WEB TPA [211500]|62.57||||62.57|43.17|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62.57||||62.57||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TML WC [212537]|62.57||||62.57|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AARP [1000]|AARP [100000]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AETNA [1015]|AETNA [101529]|125.14||||125.14|56.31|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AMBETTER [2930]|AMBETTER [293000]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|125.14||||125.14|62.57|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|125.14||||125.14|50.06|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|125.14||||125.14|50.06|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|125.14||||125.14|58.82|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|125.14||||125.14|51.31|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA PPO [126025]|125.14||||125.14|50.06|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|125.14||||125.14|62.57|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|125.14||||125.14|56.31|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|125.14||||125.14|56.31|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|Self-pay|Self-pay|125.14||||125.14|25.03|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|TML [1980]|TML [198000]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|125.14||||125.14|17.52|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UNICARE [2040]|UNICARE [204000]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|125.14||||125.14|0|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WEB TPA [2115]|WEB TPA [211500]|125.14||||125.14|86.35|86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|125.14||||125.14||86.35|8.76
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WORKER'S COMP [2125]|TML WC [212537]|125.14||||125.14|0|86.35|8.76
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AARP [1000]|AARP [100000]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AETNA [1015]|AETNA [101529]|671.62||||671.62|302.23|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMBETTER [2930]|AMBETTER [293000]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|671.62||||671.62|335.81|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|671.62||||671.62|268.65|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|671.62||||671.62|268.65|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|671.62||||671.62|315.66|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|671.62||||671.62|275.36|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA [1260]|CIGNA PPO [126025]|671.62||||671.62|268.65|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|GROUP PENSION ADMIN [1450]|GPA [145000]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|671.62||||671.62|335.81|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|671.62||||671.62|302.23|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|671.62||||671.62|302.23|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|PHCS [1780]|PHCS MULTIPLAN [178000]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|Self-pay|Self-pay|671.62||||671.62|134.32|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|TML [1980]|TML [198000]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|671.62||||671.62|94.03|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UNICARE [2040]|UNICARE [204000]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|671.62||||671.62|0|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WEB TPA [2115]|WEB TPA [211500]|671.62||||671.62|463.42|463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|671.62||||671.62||463.42|94.03
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WORKER'S COMP [2125]|TML WC [212537]|671.62||||671.62|0|463.42|94.03
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AARP [1000]|AARP [100000]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA [1015]|AETNA [101529]|170.94||||170.94|76.92|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMBETTER [2930]|AMBETTER [293000]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|170.94||||170.94|85.47|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.94||||170.94|68.38|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.94||||170.94|68.38|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.94||||170.94|80.34|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|170.94||||170.94|70.09|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA [1260]|CIGNA PPO [126025]|170.94||||170.94|68.38|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|GROUP PENSION ADMIN [1450]|GPA [145000]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|170.94||||170.94|85.47|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.94||||170.94|76.92|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.94||||170.94|76.92|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|PHCS [1780]|PHCS MULTIPLAN [178000]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|Self-pay|Self-pay|170.94||||170.94|34.19|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|TML [1980]|TML [198000]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.94||||170.94|23.93|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNICARE [2040]|UNICARE [204000]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.94||||170.94|0|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WEB TPA [2115]|WEB TPA [211500]|170.94||||170.94|117.95|117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.94||||170.94||117.95|23.93
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WORKER'S COMP [2125]|TML WC [212537]|170.94||||170.94|0|117.95|23.93
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.64||||2.64|1.19|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.06|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.06|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.24|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|1.08|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|1.19|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|1.19|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.64||||2.64|0.53|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|0.37|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64|0|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.64||||2.64||1.82|0.37
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64|0|1.82|0.37
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|8617.4||||8617.4|686.84|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|8617.4||||8617.4|898|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|8617.4||||8617.4|282.44|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8617.4||||8617.4|4308.7|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8617.4||||8617.4|3446.96|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8617.4||||8617.4|3446.96|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8617.4||||8617.4|4050.18|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8617.4||||8617.4|3533.13|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|8617.4||||8617.4|1676.2|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8617.4||||8617.4|686.84|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8617.4||||8617.4|4308.7|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8617.4||||8617.4|898|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8617.4||||8617.4|898|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8617.4||||8617.4|0|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|Self-pay|Self-pay|8617.4||||8617.4|1723.48|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|TML [1980]|TML [198000]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8617.4||||8617.4|404.3|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8617.4||||8617.4|686.84|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|8617.4||||8617.4|686.84|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8617.4||||8617.4|686.84|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|8617.4||||8617.4|5946.01|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8617.4||||8617.4|268.99|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8617.4||||8617.4|505.6|5946.01|268.99
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|8617.4||||8617.4|686.84|5946.01|268.99
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AARP [1000]|AARP [100000]|5542.5||||5542.5|423.11|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|5542.5||||5542.5|898|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5542.5||||5542.5|219.12|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5542.5||||5542.5|2771.25|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5542.5||||5542.5|2217|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5542.5||||5542.5|2217|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5542.5||||5542.5|2604.98|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5542.5||||5542.5|2272.43|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5542.5||||5542.5|1009.22|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5542.5||||5542.5|423.11|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5542.5||||5542.5|2771.25|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5542.5||||5542.5|898|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5542.5||||5542.5|898|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5542.5||||5542.5|0|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|Self-pay|Self-pay|5542.5||||5542.5|1108.5|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|TML [1980]|TML [198000]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5542.5||||5542.5|232.31|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5542.5||||5542.5|423.11|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5542.5||||5542.5|423.11|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5542.5||||5542.5|423.11|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5542.5||||5542.5|3824.33|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5542.5||||5542.5|208.68|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5542.5||||5542.5|417.37|3824.33|208.68
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5542.5||||5542.5|423.11|3824.33|208.68
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|TML [1980]|TML [198000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01||0.01|0.01
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.22||||11.22|5.05|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.22||||11.22|5.61|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.22||||11.22|4.49|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.22||||11.22|4.49|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.22||||11.22|5.27|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.22||||11.22|4.6|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.22||||11.22|4.49|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.22||||11.22|5.61|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.22||||11.22|5.05|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.22||||11.22|5.05|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|11.22||||11.22|2.24|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.22||||11.22|1.57|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.22||||11.22|0|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.22||||11.22|7.74|7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.22||||11.22||7.74|1.57
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.22||||11.22|0|7.74|1.57
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.01||||5.01|2.25|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.01||||5.01|2.51|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.01||||5.01|2|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.01||||5.01|2|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.01||||5.01|2.35|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.01||||5.01|2.05|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.01||||5.01|2|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.01||||5.01|2.51|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.01||||5.01|2.25|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.01||||5.01|2.25|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|Self-pay|Self-pay|5.01||||5.01|1|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.01||||5.01|0.7|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.01||||5.01|0|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.01||||5.01|3.46|3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.01||||5.01||3.46|0.7
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.01||||5.01|0|3.46|0.7
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|1188||||1188|534.6|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1188||||1188|594|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1188||||1188|475.2|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1188||||1188|475.2|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1188||||1188|558.36|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1188||||1188|487.08|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1188||||1188|475.2|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1188||||1188|594|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1188||||1188|534.6|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1188||||1188|534.6|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|Self-pay|Self-pay|1188||||1188|237.6|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|TML [1980]|TML [198000]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1188||||1188|166.32|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1188||||1188|0|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|1188||||1188|819.72|819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1188||||1188||819.72|166.32
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1188||||1188|0|819.72|166.32
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|18.35||||18.35|8.26|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.35||||18.35|9.18|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.35||||18.35|7.34|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.35||||18.35|7.34|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.35||||18.35|8.62|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.35||||18.35|7.52|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|18.35||||18.35|7.34|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.35||||18.35|9.18|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.35||||18.35|8.26|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.35||||18.35|8.26|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|18.35||||18.35|3.67|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.35||||18.35|2.57|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.35||||18.35|0|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|18.35||||18.35|12.66|12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.35||||18.35||12.66|2.57
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|18.35||||18.35|0|12.66|2.57
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.07||||7.07|3.18|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.07||||7.07|3.54|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.07||||7.07|2.83|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.07||||7.07|2.83|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.07||||7.07|3.32|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.07||||7.07|2.9|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.07||||7.07|2.83|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.07||||7.07|3.54|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.07||||7.07|3.18|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.07||||7.07|3.18|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.07||||7.07|1.41|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.07||||7.07|0.99|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.07||||7.07|0|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.07||||7.07|4.88|4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.07||||7.07||4.88|0.99
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.07||||7.07|0|4.88|0.99
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|71.28||||71.28|32.08|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|71.28||||71.28|35.64|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.28||||71.28|28.51|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.28||||71.28|28.51|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.28||||71.28|33.5|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|71.28||||71.28|29.22|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|71.28||||71.28|28.51|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|71.28||||71.28|35.64|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.28||||71.28|32.08|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.28||||71.28|32.08|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|71.28||||71.28|14.26|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.28||||71.28|9.98|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|71.28||||71.28|49.18|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.28||||71.28||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|71.28||||71.28|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|139.26||||139.26|62.67|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139.26||||139.26|69.63|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.26||||139.26|55.7|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.26||||139.26|55.7|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.26||||139.26|65.45|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139.26||||139.26|57.1|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|139.26||||139.26|55.7|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139.26||||139.26|69.63|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.26||||139.26|62.67|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.26||||139.26|62.67|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|139.26||||139.26|27.85|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.26||||139.26|19.5|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.26||||139.26|0|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|139.26||||139.26|96.09|96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.26||||139.26||96.09|9.98
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|139.26||||139.26|0|96.09|9.98
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|59.93||||59.93|26.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.93||||59.93|29.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.93||||59.93|23.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.93||||59.93|23.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.93||||59.93|28.17|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.93||||59.93|24.57|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|59.93||||59.93|23.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.93||||59.93|29.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.93||||59.93|26.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.93||||59.93|26.97|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|59.93||||59.93|11.99|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.93||||59.93|8.39|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.93||||59.93|0|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|59.93||||59.93|41.35|41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.93||||59.93||41.35|8.39
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|59.93||||59.93|0|41.35|8.39
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|19.94||||19.94|8.97|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.94||||19.94|9.97|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.94||||19.94|7.98|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.94||||19.94|7.98|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.94||||19.94|9.37|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.94||||19.94|8.18|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|19.94||||19.94|7.98|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.94||||19.94|9.97|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.94||||19.94|8.97|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.94||||19.94|8.97|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|19.94||||19.94|3.99|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.94||||19.94|2.79|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.94||||19.94|0|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|19.94||||19.94|13.76|13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.94||||19.94||13.76|2.79
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|19.94||||19.94|0|13.76|2.79
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|580.8||||580.8|261.36|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.8||||580.8|290.4|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580.8||||580.8|232.32|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580.8||||580.8|232.32|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580.8||||580.8|272.98|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.8||||580.8|238.13|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|580.8||||580.8|232.32|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.8||||580.8|290.4|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.8||||580.8|261.36|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.8||||580.8|261.36|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|580.8||||580.8|116.16|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|TML [1980]|TML [198000]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580.8||||580.8|81.31|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.8||||580.8|0|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|580.8||||580.8|400.75|400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580.8||||580.8||400.75|81.31
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|580.8||||580.8|0|400.75|81.31
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.95||||2.95|1.33|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.95||||2.95|1.48|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.95||||2.95|1.18|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.95||||2.95|1.18|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.95||||2.95|1.39|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.95||||2.95|1.21|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.95||||2.95|1.18|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.95||||2.95|1.48|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.95||||2.95|1.33|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.95||||2.95|1.33|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.95||||2.95|0.59|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.95||||2.95|0.41|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.95||||2.95|0|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.95||||2.95|2.04|2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.95||||2.95||2.04|0.41
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.95||||2.95|0|2.04|0.41
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.34||||2.34|1.05|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.34||||2.34|1.17|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.34||||2.34|0.94|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.34||||2.34|0.94|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.34||||2.34|1.1|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.34||||2.34|0.96|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.34||||2.34|0.94|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.34||||2.34|1.17|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.34||||2.34|1.05|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.34||||2.34|1.05|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.34||||2.34|0.47|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.34||||2.34|0.33|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.34||||2.34|0|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.34||||2.34|1.61|1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.34||||2.34||1.61|0.33
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.34||||2.34|0|1.61|0.33
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.62||||2.62|1.18|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.62||||2.62|1.31|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.62||||2.62|1.05|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.62||||2.62|1.05|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.62||||2.62|1.23|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.62||||2.62|1.07|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.62||||2.62|1.05|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.62||||2.62|1.31|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.62||||2.62|1.18|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.62||||2.62|1.18|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|2.62||||2.62|0.52|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.62||||2.62|0.37|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.62||||2.62|0|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.62||||2.62|1.81|1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.62||||2.62||1.81|0.37
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.62||||2.62|0|1.81|0.37
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.22||||2.22|1|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.22||||2.22|1.11|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.22||||2.22|0.89|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.22||||2.22|0.89|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.22||||2.22|1.04|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.22||||2.22|0.91|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.22||||2.22|0.89|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.22||||2.22|1.11|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.22||||2.22|1|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.22||||2.22|1|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.22||||2.22|0.44|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.22||||2.22|0.31|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.22||||2.22|0|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.22||||2.22|1.53|1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.22||||2.22||1.53|0.31
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.22||||2.22|0|1.53|0.31
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.94||||8.94|4.02|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.94||||8.94|4.47|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.94||||8.94|3.58|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.94||||8.94|3.58|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.94||||8.94|4.2|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.94||||8.94|3.67|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.94||||8.94|3.58|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.94||||8.94|4.47|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.94||||8.94|4.02|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.94||||8.94|4.02|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|Self-pay|Self-pay|8.94||||8.94|1.79|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.94||||8.94|1.25|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.94||||8.94|0|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.94||||8.94|6.17|6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.94||||8.94||6.17|1.25
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.94||||8.94|0|6.17|1.25
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|26.6||||26.6|11.97|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.6||||26.6|13.3|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.6||||26.6|10.64|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.6||||26.6|10.64|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.6||||26.6|12.5|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.6||||26.6|10.91|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|26.6||||26.6|10.64|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.6||||26.6|13.3|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.6||||26.6|11.97|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.6||||26.6|11.97|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|Self-pay|Self-pay|26.6||||26.6|5.32|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.6||||26.6|3.72|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.6||||26.6|0|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|26.6||||26.6|18.35|18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.6||||26.6||18.35|3.72
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|26.6||||26.6|0|18.35|3.72
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|3960||||3960|1782|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3960||||3960|1980|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3960||||3960|1584|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3960||||3960|1584|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3960||||3960|1861.2|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3960||||3960|1623.6|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|3960||||3960|1584|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3960||||3960|1980|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3960||||3960|1782|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3960||||3960|1782|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|3960||||3960|792|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3960||||3960|554.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3960||||3960|0|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|3960||||3960|2732.4|2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3960||||3960||2732.4|554.4
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|3960||||3960|0|2732.4|554.4
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|239.32||||239.32|107.69|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|239.32||||239.32|119.66|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239.32||||239.32|95.73|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239.32||||239.32|95.73|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239.32||||239.32|112.48|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|239.32||||239.32|98.12|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|239.32||||239.32|95.73|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|239.32||||239.32|119.66|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239.32||||239.32|107.69|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239.32||||239.32|107.69|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|239.32||||239.32|47.86|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239.32||||239.32|33.5|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239.32||||239.32|0|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|239.32||||239.32|165.13|165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239.32||||239.32||165.13|33.5
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|239.32||||239.32|0|165.13|33.5
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.49||||2.49|1.12|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.49||||2.49|1.25|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.49||||2.49|1|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.49||||2.49|1|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.49||||2.49|1.17|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.49||||2.49|1.02|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.49||||2.49|1|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.49||||2.49|1.25|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.49||||2.49|1.12|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.49||||2.49|1.12|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.49||||2.49|0.5|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.49||||2.49|0.35|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.49||||2.49|0|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.49||||2.49|1.72|1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.49||||2.49||1.72|0.35
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.49||||2.49|0|1.72|0.35
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.46||||5.46|2.46|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.46||||5.46|2.73|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.46||||5.46|2.18|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.46||||5.46|2.18|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.46||||5.46|2.57|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.46||||5.46|2.24|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.46||||5.46|2.18|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.46||||5.46|2.73|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.46||||5.46|2.46|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.46||||5.46|2.46|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|5.46||||5.46|1.09|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.46||||5.46|0.76|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.46||||5.46|0|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.46||||5.46|3.77|3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.46||||5.46||3.77|0.76
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.46||||5.46|0|3.77|0.76
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.44||||0.44|0.2|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.44||||0.44|0.22|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.44||||0.44|0.18|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.44||||0.44|0.18|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.44||||0.44|0.21|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.44||||0.44|0.18|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.44||||0.44|0.18|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.44||||0.44|0.22|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.44||||0.44|0.2|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.44||||0.44|0.2|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.44||||0.44|0.09|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.44||||0.44|0.06|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.44||||0.44|0|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.44||||0.44|0.3|0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.44||||0.44||0.3|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.44||||0.44|0|0.3|0.06
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.09||||3.09|1.39|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.09||||3.09|1.55|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.09||||3.09|1.24|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.09||||3.09|1.24|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.09||||3.09|1.45|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.09||||3.09|1.27|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.09||||3.09|1.24|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.09||||3.09|1.55|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.09||||3.09|1.39|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.09||||3.09|1.39|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.09||||3.09|0.62|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.09||||3.09|0.43|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.09||||3.09|0|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.09||||3.09|2.13|2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.09||||3.09||2.13|0.43
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.09||||3.09|0|2.13|0.43
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|486.42||||486.42|218.89|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AMBETTER [2930]|AMBETTER [293000]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|486.42||||486.42|243.21|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|486.42||||486.42|194.57|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|486.42||||486.42|194.57|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|486.42||||486.42|228.62|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|486.42||||486.42|199.43|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA PPO [126025]|486.42||||486.42|194.57|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|486.42||||486.42|243.21|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|486.42||||486.42|218.89|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|486.42||||486.42|218.89|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|486.42||||486.42|97.28|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|TML [1980]|TML [198000]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|486.42||||486.42|68.1|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UNICARE [2040]|UNICARE [204000]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|486.42||||486.42|0|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WEB TPA [2115]|WEB TPA [211500]|486.42||||486.42|335.63|335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|486.42||||486.42||335.63|68.1
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TML WC [212537]|486.42||||486.42|0|335.63|68.1
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.76||||0.76|0.34|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.76||||0.76|0.38|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.76||||0.76|0.3|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.76||||0.76|0.3|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.76||||0.76|0.36|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.76||||0.76|0.31|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.76||||0.76|0.3|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.76||||0.76|0.38|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.76||||0.76|0.34|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.76||||0.76|0.34|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|0.76||||0.76|0.15|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.76||||0.76|0.11|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.76||||0.76|0|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.76||||0.76|0.52|0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.76||||0.76||0.52|0.11
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.76||||0.76|0|0.52|0.11
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|66.69||||66.69|30.01|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.69||||66.69|33.35|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.69||||66.69|26.68|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.69||||66.69|26.68|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.69||||66.69|31.34|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.69||||66.69|27.34|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|66.69||||66.69|26.68|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.69||||66.69|33.35|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.69||||66.69|30.01|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.69||||66.69|30.01|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|Self-pay|Self-pay|66.69||||66.69|13.34|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.69||||66.69|9.34|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.69||||66.69|0|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|66.69||||66.69|46.02|46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.69||||66.69||46.02|9.34
6738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRAZINAMIDE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|66.69||||66.69|0|46.02|9.34
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.84||||0.84|0.38|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.84||||0.84|0.42|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.84||||0.84|0.34|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.84||||0.84|0.34|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.84||||0.84|0.39|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.84||||0.84|0.34|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.84||||0.84|0.34|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.84||||0.84|0.42|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.84||||0.84|0.38|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.84||||0.84|0.38|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.84||||0.84|0.17|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.84||||0.84|0.12|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.84||||0.84|0|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.84||||0.84|0.58|0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.84||||0.84||0.58|0.12
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.84||||0.84|0|0.58|0.12
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.27||||3.27|1.47|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.27||||3.27|1.64|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.27||||3.27|1.31|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.27||||3.27|1.31|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.27||||3.27|1.54|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.27||||3.27|1.34|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.27||||3.27|1.31|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.27||||3.27|1.64|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.27||||3.27|1.47|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.27||||3.27|1.47|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|Self-pay|Self-pay|3.27||||3.27|0.65|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.27||||3.27|0.46|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.27||||3.27|0|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.27||||3.27|2.26|2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.27||||3.27||2.26|0.46
6777|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUINIDINE SULFATE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.27||||3.27|0|2.26|0.46
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.63||||0.63|0.28|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.63||||0.63|0.32|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.63||||0.63|0.25|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.63||||0.63|0.25|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.63||||0.63|0.3|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.63||||0.63|0.26|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.63||||0.63|0.25|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.63||||0.63|0.32|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.63||||0.63|0.28|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.63||||0.63|0.28|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|Self-pay|Self-pay|0.63||||0.63|0.13|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.63||||0.63|0.09|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.63||||0.63|0|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.63||||0.63|0.43|0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.63||||0.63||0.43|0.09
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.63||||0.63|0|0.43|0.09
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|15.41||||15.41|6.93|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.41||||15.41|7.71|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.41||||15.41|6.16|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.41||||15.41|6.16|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.41||||15.41|7.24|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.41||||15.41|6.32|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|15.41||||15.41|6.16|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.41||||15.41|7.71|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.41||||15.41|6.93|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.41||||15.41|6.93|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|15.41||||15.41|3.08|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.41||||15.41|2.16|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.41||||15.41|0|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|15.41||||15.41|10.63|10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.41||||15.41||10.63|2.16
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|15.41||||15.41|0|10.63|2.16
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|2327.96||||2327.96|1047.58|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2327.96||||2327.96|1163.98|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2327.96||||2327.96|931.18|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2327.96||||2327.96|931.18|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2327.96||||2327.96|1094.14|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2327.96||||2327.96|954.46|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2327.96||||2327.96|931.18|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2327.96||||2327.96|1163.98|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2327.96||||2327.96|1047.58|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2327.96||||2327.96|1047.58|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|2327.96||||2327.96|465.59|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2327.96||||2327.96|325.91|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2327.96||||2327.96|0|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|2327.96||||2327.96|1606.29|1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2327.96||||2327.96||1606.29|325.91
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2327.96||||2327.96|0|1606.29|325.91
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|4.23||||4.23|1.9|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.23||||4.23|2.12|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.23||||4.23|1.69|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.23||||4.23|1.69|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.23||||4.23|1.99|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.23||||4.23|1.73|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|4.23||||4.23|1.69|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.23||||4.23|2.12|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.23||||4.23|1.9|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.23||||4.23|1.9|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|4.23||||4.23|0.85|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.23||||4.23|0.59|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.23||||4.23|0|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|4.23||||4.23|2.92|2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.23||||4.23||2.92|0.59
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|4.23||||4.23|0|2.92|0.59
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.24||||9.24|4.16|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.24||||9.24|4.62|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.24||||9.24|3.7|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.24||||9.24|3.7|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.24||||9.24|4.34|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.24||||9.24|3.79|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.24||||9.24|3.7|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.24||||9.24|4.62|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|4.16|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.24||||9.24|4.16|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|Self-pay|Self-pay|9.24||||9.24|1.85|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.24||||9.24|1.29|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.24||||9.24|0|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.24||||9.24|6.38|6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.24||||9.24||6.38|1.29
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.24||||9.24|0|6.38|1.29
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|90.46||||90.46|40.71|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.46||||90.46|45.23|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.46||||90.46|36.18|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.46||||90.46|36.18|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.46||||90.46|42.52|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.46||||90.46|37.09|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.46||||90.46|36.18|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.46||||90.46|45.23|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.46||||90.46|40.71|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.46||||90.46|40.71|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|90.46||||90.46|18.09|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.46||||90.46|12.66|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.46||||90.46|0|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.46||||90.46|62.42|62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.46||||90.46||62.42|12.66
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.46||||90.46|0|62.42|12.66
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|81.65||||81.65|36.74|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.65||||81.65|40.83|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.65||||81.65|32.66|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.65||||81.65|32.66|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.65||||81.65|38.38|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.65||||81.65|33.48|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|81.65||||81.65|32.66|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.65||||81.65|40.83|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.65||||81.65|36.74|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.65||||81.65|36.74|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|Self-pay|Self-pay|81.65||||81.65|16.33|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.65||||81.65|11.43|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.65||||81.65|0|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|81.65||||81.65|56.34|56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.65||||81.65||56.34|11.43
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|81.65||||81.65|0|56.34|11.43
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AARP [1000]|AARP [100000]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AETNA [1015]|AETNA [101529]|237.6||||237.6|106.92|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMBETTER [2930]|AMBETTER [293000]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.6||||237.6|118.8|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.6||||237.6|95.04|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.6||||237.6|95.04|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.6||||237.6|111.67|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.6||||237.6|97.42|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA [1260]|CIGNA PPO [126025]|237.6||||237.6|95.04|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|GROUP PENSION ADMIN [1450]|GPA [145000]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.6||||237.6|118.8|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.6||||237.6|106.92|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.6||||237.6|106.92|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|PHCS [1780]|PHCS MULTIPLAN [178000]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|Self-pay|Self-pay|237.6||||237.6|47.52|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|TML [1980]|TML [198000]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.6||||237.6|33.26|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNICARE [2040]|UNICARE [204000]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.6||||237.6|0|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WEB TPA [2115]|WEB TPA [211500]|237.6||||237.6|163.94|163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237.6||||237.6||163.94|33.26
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WORKER'S COMP [2125]|TML WC [212537]|237.6||||237.6|0|163.94|33.26
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AARP [1000]|AARP [100000]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|AETNA [101529]|3758.04||||3758.04|1691.12|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AMBETTER [2930]|AMBETTER [293000]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3758.04||||3758.04|1879.02|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3758.04||||3758.04|1503.22|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3758.04||||3758.04|1503.22|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3758.04||||3758.04|1766.28|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3758.04||||3758.04|1540.8|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA [1260]|CIGNA PPO [126025]|3758.04||||3758.04|1503.22|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3758.04||||3758.04|1879.02|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3758.04||||3758.04|1691.12|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3758.04||||3758.04|1691.12|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|Self-pay|Self-pay|3758.04||||3758.04|751.61|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|TML [1980]|TML [198000]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3758.04||||3758.04|526.13|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UNICARE [2040]|UNICARE [204000]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3758.04||||3758.04|0|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WEB TPA [2115]|WEB TPA [211500]|3758.04||||3758.04|2593.05|2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3758.04||||3758.04||2593.05|526.13
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|TML WC [212537]|3758.04||||3758.04|0|2593.05|526.13
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.27|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.59||||0.59|0.3|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.24|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.24|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.28|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.59||||0.59|0.24|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.59||||0.59|0.24|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.59||||0.59|0.3|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.27|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.27|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.12|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|TML [1980]|TML [198000]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.08|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59|0|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.59||||0.59|0.41|0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||0.41|0.08
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.59||||0.59|0|0.41|0.08
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.86||||0.86|0.39|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.86||||0.86|0.43|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.86||||0.86|0.34|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.86||||0.86|0.34|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.86||||0.86|0.4|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.86||||0.86|0.35|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.86||||0.86|0.34|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.86||||0.86|0.43|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.86||||0.86|0.39|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.86||||0.86|0.39|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.86||||0.86|0.17|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.86||||0.86|0.12|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.86||||0.86|0|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.86||||0.86|0.59|0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.86||||0.86||0.59|0.12
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.86||||0.86|0|0.59|0.12
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.21||||1.21|0.54|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.21||||1.21|0.61|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.48|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.48|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.57|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.21||||1.21|0.5|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.21||||1.21|0.48|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.21||||1.21|0.61|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0.54|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0.54|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.21||||1.21|0.24|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.17|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21|0|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.21||||1.21|0.83|0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21||0.83|0.17
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.21||||1.21|0|0.83|0.17
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AARP [1000]|AARP [100000]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AETNA [1015]|AETNA [101529]|161.7||||161.7|72.77|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AMBETTER [2930]|AMBETTER [293000]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|161.7||||161.7|80.85|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161.7||||161.7|64.68|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161.7||||161.7|64.68|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161.7||||161.7|76|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|161.7||||161.7|66.3|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA [1260]|CIGNA PPO [126025]|161.7||||161.7|64.68|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|GROUP PENSION ADMIN [1450]|GPA [145000]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|161.7||||161.7|80.85|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161.7||||161.7|72.77|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161.7||||161.7|72.77|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|PHCS [1780]|PHCS MULTIPLAN [178000]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|Self-pay|Self-pay|161.7||||161.7|32.34|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|TML [1980]|TML [198000]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161.7||||161.7|22.64|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UNICARE [2040]|UNICARE [204000]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161.7||||161.7|0|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WEB TPA [2115]|WEB TPA [211500]|161.7||||161.7|111.57|111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161.7||||161.7||111.57|22.64
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WORKER'S COMP [2125]|TML WC [212537]|161.7||||161.7|0|111.57|22.64
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AARP [1000]|AARP [100000]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|137.55||||137.55|61.9|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|137.55||||137.55|68.78|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|137.55||||137.55|55.02|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|137.55||||137.55|55.02|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|137.55||||137.55|64.65|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|137.55||||137.55|56.4|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|137.55||||137.55|55.02|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|137.55||||137.55|68.78|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|137.55||||137.55|61.9|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|137.55||||137.55|61.9|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|Self-pay|Self-pay|137.55||||137.55|27.51|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|TML [1980]|TML [198000]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|137.55||||137.55|19.26|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|137.55||||137.55|0|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|137.55||||137.55|94.91|94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|137.55||||137.55||94.91|19.26
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|137.55||||137.55|0|94.91|19.26
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|41.72||||41.72|18.77|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.72||||41.72|20.86|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.72||||41.72|16.69|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.72||||41.72|16.69|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.72||||41.72|19.61|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.72||||41.72|17.11|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|41.72||||41.72|16.69|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.72||||41.72|20.86|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.72||||41.72|18.77|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.72||||41.72|18.77|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|41.72||||41.72|8.34|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.72||||41.72|5.84|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.72||||41.72|0|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|41.72||||41.72|28.79|28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.72||||41.72||28.79|5.84
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|41.72||||41.72|0|28.79|5.84
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AARP [1000]|AARP [100000]|1035||||1035|298|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1035||||1035|50.47|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA [1015]|AETNA [101529]|1035||||1035|465.75|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMBETTER [2930]|AMBETTER [293000]|1035||||1035|56.21|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1035||||1035|57.78|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1035||||1035|517.5|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1035||||1035|50.47|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1035||||1035|414|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1035||||1035|414|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1035||||1035|486.45|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1035||||1035|424.35|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1035||||1035|57.78|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|1035||||1035|414|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1035||||1035|298|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1035||||1035|517.5|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1035||||1035|57.78|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1035||||1035|465.75|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1035||||1035|57.78|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1035||||1035|465.75|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1035||||1035|0|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|Self-pay|Self-pay|1035||||1035|207|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|TML [1980]|TML [198000]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1035||||1035|144.9|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1035||||1035|298|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNICARE [2040]|UNICARE [204000]|1035||||1035|298|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1035||||1035|298|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WEB TPA [2115]|WEB TPA [211500]|1035||||1035|714.15|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1035||||1035|57.78|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1035||||1035|115.57|714.15|50.47
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|1035||||1035|298|714.15|50.47
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AARP [1000]|AARP [100000]|108||||108|108|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AETNA [1015]|AETNA [101529]|108||||108|48.6|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AMBETTER [2930]|AMBETTER [293000]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108||||108|54|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108||||108|43.2|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108||||108|43.2|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108||||108|50.76|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108||||108|44.28|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA [1260]|CIGNA PPO [126025]|108||||108|43.2|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108||||108|108|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108||||108|54|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108||||108|48.6|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108||||108|48.6|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108||||108|0|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|Self-pay|Self-pay|108||||108|21.6|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|TML [1980]|TML [198000]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108||||108|15.12|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108||||108|108|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UNICARE [2040]|UNICARE [204000]|108||||108|108|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108||||108|108|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WEB TPA [2115]|WEB TPA [211500]|108||||108|74.52|108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108||||108||108|15.12
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WORKER'S COMP [2125]|TML WC [212537]|108||||108|108|108|15.12
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.77||||0.77|0.35|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.77||||0.77|0.39|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.77||||0.77|0.31|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.77||||0.77|0.31|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.77||||0.77|0.36|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.77||||0.77|0.32|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.77||||0.77|0.31|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.77||||0.77|0.39|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.77||||0.77|0.35|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.77||||0.77|0.35|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|Self-pay|Self-pay|0.77||||0.77|0.15|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.77||||0.77|0.11|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.77||||0.77|0|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.77||||0.77|0.53|0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.77||||0.77||0.53|0.11
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.77||||0.77|0|0.53|0.11
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AARP [1000]|AARP [100000]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|23.76|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|26.4|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.8||||52.8|21.12|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.8||||52.8|21.12|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.8||||52.8|24.82|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|21.65|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|26.4|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|23.76|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|23.76|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|Self-pay|Self-pay|52.8||||52.8|10.56|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.8||||52.8|7.39|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8|0|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.8||||52.8||36.43|7.39
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8|0|36.43|7.39
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|155.76||||155.76|70.09|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|155.76||||155.76|77.88|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155.76||||155.76|62.3|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155.76||||155.76|62.3|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155.76||||155.76|73.21|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|155.76||||155.76|63.86|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|155.76||||155.76|62.3|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|155.76||||155.76|77.88|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155.76||||155.76|70.09|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155.76||||155.76|70.09|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|155.76||||155.76|31.15|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155.76||||155.76|21.81|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155.76||||155.76|0|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|155.76||||155.76|107.47|107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155.76||||155.76||107.47|21.81
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|155.76||||155.76|0|107.47|21.81
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AARP [1000]|AARP [100000]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AETNA [1015]|AETNA [101529]|1.67||||1.67|0.75|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AMBETTER [2930]|AMBETTER [293000]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.67||||1.67|0.84|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.67||||1.67|0.67|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.67||||1.67|0.67|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.67||||1.67|0.78|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.67||||1.67|0.68|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|1.67||||1.67|0.67|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.67||||1.67|0.84|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.67||||1.67|0.75|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.67||||1.67|0.75|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|Self-pay|Self-pay|1.67||||1.67|0.33|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|TML [1980]|TML [198000]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.67||||1.67|0.23|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UNICARE [2040]|UNICARE [204000]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.67||||1.67|0|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WEB TPA [2115]|WEB TPA [211500]|1.67||||1.67|1.15|1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.67||||1.67||1.15|0.23
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|1.67||||1.67|0|1.15|0.23
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.06||||1.06|0.48|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.06||||1.06|0.53|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.06||||1.06|0.42|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.42|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.06||||1.06|0.5|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.06||||1.06|0.43|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.06||||1.06|0.42|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.06||||1.06|0.53|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0.48|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0.48|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|1.06||||1.06|0.21|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.06||||1.06|0.15|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06|0|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.06||||1.06|0.73|0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.06||||1.06||0.73|0.15
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.06||||1.06|0|0.73|0.15
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|155.63||||155.63|70.03|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|155.63||||155.63|77.82|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155.63||||155.63|62.25|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155.63||||155.63|62.25|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155.63||||155.63|73.15|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|155.63||||155.63|63.81|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|155.63||||155.63|62.25|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|155.63||||155.63|77.82|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155.63||||155.63|70.03|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155.63||||155.63|70.03|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|Self-pay|Self-pay|155.63||||155.63|31.13|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|TML [1980]|TML [198000]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155.63||||155.63|21.79|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155.63||||155.63|0|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|155.63||||155.63|107.38|107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155.63||||155.63||107.38|21.79
7332|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|155.63||||155.63|0|107.38|21.79
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|82.9||||82.9|37.31|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82.9||||82.9|41.45|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82.9||||82.9|33.16|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82.9||||82.9|33.16|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82.9||||82.9|38.96|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82.9||||82.9|33.99|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|82.9||||82.9|33.16|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82.9||||82.9|41.45|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.9||||82.9|37.31|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82.9||||82.9|37.31|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|82.9||||82.9|16.58|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82.9||||82.9|11.61|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82.9||||82.9|0|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|82.9||||82.9|57.2|57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82.9||||82.9||57.2|11.61
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|82.9||||82.9|0|57.2|11.61
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|435.8||||435.8|196.11|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|435.8||||435.8|217.9|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|435.8||||435.8|174.32|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|435.8||||435.8|174.32|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|435.8||||435.8|204.83|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|435.8||||435.8|178.68|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|435.8||||435.8|174.32|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|435.8||||435.8|217.9|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|435.8||||435.8|196.11|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|435.8||||435.8|196.11|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|435.8||||435.8|87.16|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|435.8||||435.8|61.01|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|435.8||||435.8|0|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|435.8||||435.8|300.7|300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|435.8||||435.8||300.7|61.01
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|435.8||||435.8|0|300.7|61.01
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|587.67||||587.67|264.45|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|587.67||||587.67|293.84|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|587.67||||587.67|235.07|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|587.67||||587.67|235.07|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|587.67||||587.67|276.2|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|587.67||||587.67|240.94|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|587.67||||587.67|235.07|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|587.67||||587.67|293.84|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|587.67||||587.67|264.45|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|587.67||||587.67|264.45|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|Self-pay|Self-pay|587.67||||587.67|117.53|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|TML [1980]|TML [198000]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|587.67||||587.67|82.27|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|587.67||||587.67|0|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|587.67||||587.67|405.49|405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|587.67||||587.67||405.49|82.27
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|587.67||||587.67|0|405.49|82.27
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|677.43||||677.43|304.84|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|677.43||||677.43|338.72|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|677.43||||677.43|270.97|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|677.43||||677.43|270.97|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|677.43||||677.43|318.39|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|677.43||||677.43|277.75|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|677.43||||677.43|270.97|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|677.43||||677.43|338.72|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|677.43||||677.43|304.84|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|677.43||||677.43|304.84|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|Self-pay|Self-pay|677.43||||677.43|135.49|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|677.43||||677.43|94.84|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|677.43||||677.43|0|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|677.43||||677.43|467.43|467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|677.43||||677.43||467.43|94.84
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|677.43||||677.43|0|467.43|94.84
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|1412.4||||1412.4|635.58|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1412.4||||1412.4|706.2|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1412.4||||1412.4|564.96|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1412.4||||1412.4|564.96|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1412.4||||1412.4|663.83|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1412.4||||1412.4|579.08|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|1412.4||||1412.4|564.96|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1412.4||||1412.4|706.2|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1412.4||||1412.4|635.58|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1412.4||||1412.4|635.58|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|1412.4||||1412.4|282.48|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1412.4||||1412.4|197.74|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1412.4||||1412.4|0|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|1412.4||||1412.4|974.56|974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1412.4||||1412.4||974.56|197.74
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|1412.4||||1412.4|0|974.56|197.74
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AARP [1000]|AARP [100000]|5990||||5990|270|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AETNA [1015]|AETNA [101529]|5990||||5990|2695.5|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AMBETTER [2930]|AMBETTER [293000]|5990||||5990|251.79|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5990||||5990|2995|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5990||||5990|2396|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5990||||5990|2396|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5990||||5990|2815.3|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5990||||5990|2455.9|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|CIGNA [1260]|CIGNA PPO [126025]|5990||||5990|2396|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5990||||5990|270|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5990||||5990|2995|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5990||||5990|2695.5|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5990||||5990|2695.5|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5990||||5990|0|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|Self-pay|Self-pay|5990||||5990|1198|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|TML [1980]|TML [198000]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5990||||5990|838.6|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5990||||5990|270|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|UNICARE [2040]|UNICARE [204000]|5990||||5990|270|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5990||||5990|270|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|WEB TPA [2115]|WEB TPA [211500]|5990||||5990|4133.1|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5990||||5990|239.8|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5990||||5990|479.61|4133.1|239.8
74095816|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/DROWSY|1|WORKER'S COMP [2125]|TML WC [212537]|5990||||5990|270|4133.1|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AARP [1000]|AARP [100000]|1866||||1866|270|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AETNA [1015]|AETNA [101529]|1866||||1866|839.7|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMBETTER [2930]|AMBETTER [293000]|1866||||1866|251.79|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1866||||1866|933|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1866||||1866|746.4|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1866||||1866|746.4|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1866||||1866|877.02|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1866||||1866|765.06|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA [1260]|CIGNA PPO [126025]|1866||||1866|746.4|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1866||||1866|270|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1866||||1866|933|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1866||||1866|839.7|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1866||||1866|839.7|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1866||||1866|0|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|Self-pay|Self-pay|1866||||1866|373.2|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|TML [1980]|TML [198000]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1866||||1866|261.24|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1866||||1866|270|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UNICARE [2040]|UNICARE [204000]|1866||||1866|270|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1866||||1866|270|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WEB TPA [2115]|WEB TPA [211500]|1866||||1866|1287.54|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1866||||1866|239.8|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1866||||1866|479.61|1287.54|239.8
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WORKER'S COMP [2125]|TML WC [212537]|1866||||1866|270|1287.54|239.8
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AARP [1000]|AARP [100000]|2103||||2103|270|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AETNA [1015]|AETNA [101529]|2103||||2103|946.35|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMBETTER [2930]|AMBETTER [293000]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2103||||2103|1051.5|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2103||||2103|841.2|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2103||||2103|841.2|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2103||||2103|988.41|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2103||||2103|862.23|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|2103||||2103|841.2|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2103||||2103|270|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2103||||2103|1051.5|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2103||||2103|946.35|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2103||||2103|946.35|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2103||||2103|0|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|Self-pay|Self-pay|2103||||2103|420.6|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|TML [1980]|TML [198000]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2103||||2103|294.42|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2103||||2103|270|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UNICARE [2040]|UNICARE [204000]|2103||||2103|270|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2103||||2103|270|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WEB TPA [2115]|WEB TPA [211500]|2103||||2103|1451.07|1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2103||||2103||1451.07|270
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|2103||||2103|270|1451.07|270
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AARP [1000]|AARP [100000]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|27.72||||27.72|12.47|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.72||||27.72|13.86|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.72||||27.72|11.09|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.72||||27.72|11.09|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.72||||27.72|13.03|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.72||||27.72|11.37|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|27.72||||27.72|11.09|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.72||||27.72|13.86|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.72||||27.72|12.47|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.72||||27.72|12.47|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|Self-pay|Self-pay|27.72||||27.72|5.54|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|TML [1980]|TML [198000]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.72||||27.72|3.88|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.72||||27.72|0|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|27.72||||27.72|19.13|19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.72||||27.72||19.13|3.88
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|27.72||||27.72|0|19.13|3.88
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.51||||2.51|1.13|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.51||||2.51|1.26|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.51||||2.51|1|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.51||||2.51|1|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.51||||2.51|1.18|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.51||||2.51|1.03|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.51||||2.51|1|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.51||||2.51|1.26|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.51||||2.51|1.13|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.51||||2.51|1.13|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.51||||2.51|0.5|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.51||||2.51|0.35|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.51||||2.51|0|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.51||||2.51|1.73|1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.51||||2.51||1.73|0.35
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.51||||2.51|0|1.73|0.35
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|17.82|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|15.84|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|15.84|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|18.61|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|16.24|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|17.82|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|17.82|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|5.54|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AARP [1000]|AARP [100000]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|71.28|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|63.36|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|63.36|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|74.45|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|64.94|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|71.28|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|71.28|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|Self-pay|Self-pay|158.4||||158.4|31.68|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|22.18|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|0|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4||109.3|5.54
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|0|109.3|5.54
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.45||||2.45|1.1|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.45||||2.45|1.23|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.45||||2.45|0.98|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.45||||2.45|0.98|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.45||||2.45|1.15|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.45||||2.45|1|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.45||||2.45|0.98|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.45||||2.45|1.23|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.45||||2.45|1.1|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.45||||2.45|1.1|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.45||||2.45|0.49|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.45||||2.45|0.34|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.45||||2.45|0|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.45||||2.45|1.69|1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.45||||2.45||1.69|0.34
7562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.45||||2.45|0|1.69|0.34
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AARP [1000]|AARP [100000]|1894||||1894|636|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AETNA [1015]|AETNA [101529]|1894||||1894|852.3|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AMBETTER [2930]|AMBETTER [293000]|1894||||1894|623.04|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1894||||1894|947|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1894||||1894|757.6|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1894||||1894|757.6|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1894||||1894|890.18|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1894||||1894|776.54|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|CIGNA [1260]|CIGNA PPO [126025]|1894||||1894|757.6|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1894||||1894|636|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1894||||1894|947|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1894||||1894|852.3|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1894||||1894|852.3|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1894||||1894|0|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|Self-pay|Self-pay|1894||||1894|378.8|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|TML [1980]|TML [198000]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1894||||1894|265.16|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1894||||1894|636|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|UNICARE [2040]|UNICARE [204000]|1894||||1894|636|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1894||||1894|636|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|WEB TPA [2115]|WEB TPA [211500]|1894||||1894|1306.86|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1894||||1894|593.37|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1894||||1894|1186.75|1306.86|265.16
76100257|EAP|0829 - HEMODIALYSIS-OUTPATIENT OR HOME-OTHER OP HE|HC DIALYSIS UNSCHED/EMERG HOSP OP ESRD|1|WORKER'S COMP [2125]|TML WC [212537]|1894||||1894|636|1306.86|265.16
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|37.85||||37.85|17.03|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.85||||37.85|18.93|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.85||||37.85|15.14|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.85||||37.85|15.14|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.85||||37.85|17.79|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.85||||37.85|15.52|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|37.85||||37.85|15.14|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.85||||37.85|18.93|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.85||||37.85|17.03|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.85||||37.85|17.03|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|37.85||||37.85|7.57|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.85||||37.85|5.3|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.85||||37.85|0|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|37.85||||37.85|26.12|26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.85||||37.85||26.12|5.3
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|37.85||||37.85|0|26.12|5.3
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|124.88||||124.88|56.2|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|124.88||||124.88|62.44|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124.88||||124.88|49.95|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124.88||||124.88|49.95|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124.88||||124.88|58.69|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|124.88||||124.88|51.2|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|124.88||||124.88|49.95|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|124.88||||124.88|62.44|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124.88||||124.88|56.2|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124.88||||124.88|56.2|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|Self-pay|Self-pay|124.88||||124.88|24.98|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|TML [1980]|TML [198000]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124.88||||124.88|17.48|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124.88||||124.88|0|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|124.88||||124.88|86.17|86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124.88||||124.88||86.17|17.48
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|124.88||||124.88|0|86.17|17.48
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|23.57||||23.57|10.61|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.57||||23.57|11.79|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.57||||23.57|9.43|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.57||||23.57|9.43|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.57||||23.57|11.08|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.57||||23.57|9.66|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|23.57||||23.57|9.43|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.57||||23.57|11.79|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.57||||23.57|10.61|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.57||||23.57|10.61|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|Self-pay|Self-pay|23.57||||23.57|4.71|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.57||||23.57|3.3|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.57||||23.57|0|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|23.57||||23.57|16.26|16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.57||||23.57||16.26|3.3
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|23.57||||23.57|0|16.26|3.3
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AARP [1000]|AARP [100000]|69||||69|21|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA [1015]|AETNA [101529]|69||||69|31.05|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|69||||69|62.59|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|34.5|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|27.6|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|27.6|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|32.43|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|28.29|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|21|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|34.5|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|31.05|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|31.05|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|0|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|Self-pay|Self-pay|69||||69|13.8|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|TML [1980]|TML [198000]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|9.66|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|21|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNICARE [2040]|UNICARE [204000]|69||||69|21|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|21|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|38.47|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69|76.95|76.95|9.66
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|21|76.95|9.66
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AARP [1000]|AARP [100000]|71.73||||71.73|21|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA [1015]|AETNA [101529]|71.73||||71.73|32.28|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|71.73||||71.73|35.87|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.73||||71.73|28.69|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.73||||71.73|28.69|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.73||||71.73|33.71|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|71.73||||71.73|29.41|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|71.73||||71.73|28.69|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|71.73||||71.73|21|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|71.73||||71.73|35.87|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.73||||71.73|32.28|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.73||||71.73|32.28|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.73||||71.73|0|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|Self-pay|Self-pay|71.73||||71.73|14.35|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|TML [1980]|TML [198000]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.73||||71.73|10.04|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.73||||71.73|21|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNICARE [2040]|UNICARE [204000]|71.73||||71.73|21|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.73||||71.73|21|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|71.73||||71.73|49.49|49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.73||||71.73||49.49|10.04
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|71.73||||71.73|21|49.49|10.04
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AARP [1000]|AARP [100000]|69||||69|21|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA [1015]|AETNA [101529]|69||||69|31.05|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|34.5|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|27.6|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|27.6|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|32.43|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|28.29|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|21|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|34.5|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|31.05|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|31.05|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|0|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|Self-pay|Self-pay|69||||69|13.8|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|TML [1980]|TML [198000]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|9.66|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|21|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNICARE [2040]|UNICARE [204000]|69||||69|21|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|21|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69||47.61|9.66
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|21|47.61|9.66
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|50.82||||50.82|22.87|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.82||||50.82|25.41|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.82||||50.82|20.33|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.82||||50.82|20.33|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.82||||50.82|23.89|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50.82||||50.82|20.84|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|50.82||||50.82|20.33|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.82||||50.82|25.41|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.82||||50.82|22.87|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.82||||50.82|22.87|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|50.82||||50.82|10.16|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.82||||50.82|7.11|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.82||||50.82|0|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|50.82||||50.82|35.07|35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.82||||50.82||35.07|7.11
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|50.82||||50.82|0|35.07|7.11
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.21||||1.21|0.54|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.21||||1.21|0.61|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.48|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.48|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.57|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.21||||1.21|0.5|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.21||||1.21|0.48|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.21||||1.21|0.61|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0.54|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0.54|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.21||||1.21|0.24|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.17|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21|0|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.21||||1.21|0.83|0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21||0.83|0.17
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.21||||1.21|0|0.83|0.17
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|2468.4||||2468.4|1110.78|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMBETTER [2930]|AMBETTER [293000]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2468.4||||2468.4|1234.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2468.4||||2468.4|987.36|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2468.4||||2468.4|987.36|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2468.4||||2468.4|1160.15|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2468.4||||2468.4|1012.04|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA PPO [126025]|2468.4||||2468.4|987.36|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2468.4||||2468.4|1234.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2468.4||||2468.4|1110.78|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2468.4||||2468.4|1110.78|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|2468.4||||2468.4|493.68|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|TML [1980]|TML [198000]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2468.4||||2468.4|345.58|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNICARE [2040]|UNICARE [204000]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2468.4||||2468.4|0|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WEB TPA [2115]|WEB TPA [211500]|2468.4||||2468.4|1703.2|1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2468.4||||2468.4||1703.2|345.58
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TML WC [212537]|2468.4||||2468.4|0|1703.2|345.58
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AARP [1000]|AARP [100000]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|24.42||||24.42|10.99|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.42||||24.42|12.21|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.42||||24.42|9.77|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.42||||24.42|9.77|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.42||||24.42|11.48|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.42||||24.42|10.01|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|24.42||||24.42|9.77|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.42||||24.42|12.21|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.42||||24.42|10.99|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.42||||24.42|10.99|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|Self-pay|Self-pay|24.42||||24.42|4.88|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|TML [1980]|TML [198000]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.42||||24.42|3.42|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.42||||24.42|0|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|24.42||||24.42|16.85|16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.42||||24.42||16.85|3.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|24.42||||24.42|0|16.85|3.42
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|16.04||||16.04|7.22|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.04||||16.04|8.02|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.04||||16.04|6.42|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.04||||16.04|6.42|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.04||||16.04|7.54|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.04||||16.04|6.58|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|16.04||||16.04|6.42|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.04||||16.04|8.02|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.04||||16.04|7.22|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.04||||16.04|7.22|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|Self-pay|Self-pay|16.04||||16.04|3.21|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|TML [1980]|TML [198000]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.04||||16.04|2.25|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.04||||16.04|0|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|16.04||||16.04|11.07|11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.04||||16.04||11.07|2.25
7800|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TETRAHYDROZOLINE 0.05 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|16.04||||16.04|0|11.07|2.25
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|7.46||||7.46|3.36|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMBETTER [2930]|AMBETTER [293000]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.46||||7.46|3.73|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.46||||7.46|2.98|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.46||||7.46|2.98|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.46||||7.46|3.51|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.46||||7.46|3.06|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA PPO [126025]|7.46||||7.46|2.98|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.46||||7.46|3.73|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.46||||7.46|3.36|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.46||||7.46|3.36|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|7.46||||7.46|1.49|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|TML [1980]|TML [198000]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.46||||7.46|1.04|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNICARE [2040]|UNICARE [204000]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.46||||7.46|0|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WEB TPA [2115]|WEB TPA [211500]|7.46||||7.46|5.15|5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.46||||7.46||5.15|1.04
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TML WC [212537]|7.46||||7.46|0|5.15|1.04
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|131.34||||131.34|59.1|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131.34||||131.34|65.67|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131.34||||131.34|52.54|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131.34||||131.34|52.54|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131.34||||131.34|61.73|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131.34||||131.34|53.85|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|131.34||||131.34|52.54|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131.34||||131.34|65.67|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131.34||||131.34|59.1|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131.34||||131.34|59.1|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|131.34||||131.34|26.27|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131.34||||131.34|18.39|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131.34||||131.34|0|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|131.34||||131.34|90.62|90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131.34||||131.34||90.62|18.39
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|131.34||||131.34|0|90.62|18.39
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AARP [1000]|AARP [100000]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AETNA [1015]|AETNA [101529]|3792.24||||3792.24|1706.51|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMBETTER [2930]|AMBETTER [293000]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3792.24||||3792.24|1896.12|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3792.24||||3792.24|1516.9|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3792.24||||3792.24|1516.9|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3792.24||||3792.24|1782.35|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3792.24||||3792.24|1554.82|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA [1260]|CIGNA PPO [126025]|3792.24||||3792.24|1516.9|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3792.24||||3792.24|1896.12|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3792.24||||3792.24|1706.51|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3792.24||||3792.24|1706.51|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|Self-pay|Self-pay|3792.24||||3792.24|758.45|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|TML [1980]|TML [198000]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3792.24||||3792.24|530.91|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UNICARE [2040]|UNICARE [204000]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3792.24||||3792.24|0|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WEB TPA [2115]|WEB TPA [211500]|3792.24||||3792.24|2616.65|2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3792.24||||3792.24||2616.65|530.91
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WORKER'S COMP [2125]|TML WC [212537]|3792.24||||3792.24|0|2616.65|530.91
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AARP [1000]|AARP [100000]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AETNA [1015]|AETNA [101529]|1540||||1540|693|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMBETTER [2930]|AMBETTER [293000]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1540||||1540|770|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1540||||1540|616|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1540||||1540|616|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1540||||1540|723.8|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1540||||1540|631.4|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA [1260]|CIGNA PPO [126025]|1540||||1540|616|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1540||||1540|770|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1540||||1540|693|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1540||||1540|693|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|Self-pay|Self-pay|1540||||1540|308|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|TML [1980]|TML [198000]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1540||||1540|215.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UNICARE [2040]|UNICARE [204000]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1540||||1540|0|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WEB TPA [2115]|WEB TPA [211500]|1540||||1540|1062.6|1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1540||||1540||1062.6|215.6
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WORKER'S COMP [2125]|TML WC [212537]|1540||||1540|0|1062.6|215.6
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|40.4||||40.4|18.18|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40.4||||40.4|20.2|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.4||||40.4|16.16|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.4||||40.4|16.16|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.4||||40.4|18.99|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40.4||||40.4|16.56|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|40.4||||40.4|16.16|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40.4||||40.4|20.2|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.4||||40.4|18.18|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.4||||40.4|18.18|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|40.4||||40.4|8.08|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.4||||40.4|5.66|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.4||||40.4|0|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|40.4||||40.4|27.88|27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.4||||40.4||27.88|5.66
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|40.4||||40.4|0|27.88|5.66
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.72||||1.72|0.77|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.72||||1.72|0.86|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.72||||1.72|0.69|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.72||||1.72|0.69|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.72||||1.72|0.81|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.72||||1.72|0.71|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.72||||1.72|0.69|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.72||||1.72|0.86|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.72||||1.72|0.77|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.72||||1.72|0.77|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.72||||1.72|0.34|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.72||||1.72|0.24|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.72||||1.72|0|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.72||||1.72|1.19|1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.72||||1.72||1.19|0.24
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.72||||1.72|0|1.19|0.24
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|61.38||||61.38|27.62|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|61.38||||61.38|30.69|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|61.38||||61.38|24.55|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|61.38||||61.38|24.55|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|61.38||||61.38|28.85|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|61.38||||61.38|25.17|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|61.38||||61.38|24.55|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|61.38||||61.38|30.69|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|61.38||||61.38|27.62|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|61.38||||61.38|27.62|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|61.38||||61.38|12.28|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|61.38||||61.38|8.59|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|61.38||||61.38|0|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|61.38||||61.38|42.35|42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|61.38||||61.38||42.35|8.59
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|61.38||||61.38|0|42.35|8.59
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|59.6||||59.6|26.82|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.6||||59.6|29.8|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.6||||59.6|23.84|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.6||||59.6|23.84|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.6||||59.6|28.01|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.6||||59.6|24.44|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|59.6||||59.6|23.84|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.6||||59.6|29.8|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.6||||59.6|26.82|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.6||||59.6|26.82|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|59.6||||59.6|11.92|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.6||||59.6|8.34|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.6||||59.6|0|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|59.6||||59.6|41.12|41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.6||||59.6||41.12|8.34
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|59.6||||59.6|0|41.12|8.34
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|106.79||||106.79|48.06|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|106.79||||106.79|53.4|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106.79||||106.79|42.72|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106.79||||106.79|42.72|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106.79||||106.79|50.19|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|106.79||||106.79|43.78|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|106.79||||106.79|42.72|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|106.79||||106.79|53.4|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.79||||106.79|48.06|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106.79||||106.79|48.06|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|106.79||||106.79|21.36|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TML [1980]|TML [198000]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106.79||||106.79|14.95|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106.79||||106.79|0|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|106.79||||106.79|73.69|73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106.79||||106.79||73.69|14.95
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|106.79||||106.79|0|73.69|14.95
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AARP [1000]|AARP [100000]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AETNA [1015]|AETNA [101529]|851.01||||851.01|382.95|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AMBETTER [2930]|AMBETTER [293000]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|851.01||||851.01|425.51|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|851.01||||851.01|340.4|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|851.01||||851.01|340.4|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|851.01||||851.01|399.97|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|851.01||||851.01|348.91|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|CIGNA [1260]|CIGNA PPO [126025]|851.01||||851.01|340.4|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|851.01||||851.01|425.51|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|851.01||||851.01|382.95|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|851.01||||851.01|382.95|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|Self-pay|Self-pay|851.01||||851.01|170.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|TML [1980]|TML [198000]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|851.01||||851.01|119.14|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|UNICARE [2040]|UNICARE [204000]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|851.01||||851.01|0|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|WEB TPA [2115]|WEB TPA [211500]|851.01||||851.01|587.2|587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|851.01||||851.01||587.2|119.14
8121|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE|5 g|WORKER'S COMP [2125]|TML WC [212537]|851.01||||851.01|0|587.2|119.14
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.19||||9.19|4.14|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.19||||9.19|4.6|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.19||||9.19|3.68|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.19||||9.19|3.68|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.19||||9.19|4.32|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.19||||9.19|3.77|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.19||||9.19|3.68|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.19||||9.19|4.6|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.19||||9.19|4.14|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.19||||9.19|4.14|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|9.19||||9.19|1.84|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.19||||9.19|1.29|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.19||||9.19|0|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.19||||9.19|6.34|6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.19||||9.19||6.34|1.29
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.19||||9.19|0|6.34|1.29
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.98||||1.98|0.89|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.98||||1.98|0.99|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.98||||1.98|0.79|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.98||||1.98|0.79|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.98||||1.98|0.93|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.98||||1.98|0.81|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.98||||1.98|0.79|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.98||||1.98|0.99|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.98||||1.98|0.89|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.98||||1.98|0.89|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.98||||1.98|0.4|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.98||||1.98|0.28|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.98||||1.98|0|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.98||||1.98|1.37|1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.98||||1.98||1.37|0.28
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.98||||1.98|0|1.37|0.28
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|18.1|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|18.1|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|18.1|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|15.79|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|15.79|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|15.79|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|17.33|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|5.39|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|5.39|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|5.39|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5||26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5|0|26.57|5.39
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5|0|26.57|5.39
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|118.44||||118.44|53.3|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.44||||118.44|59.22|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.44||||118.44|47.38|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.44||||118.44|47.38|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.44||||118.44|55.67|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.44||||118.44|48.56|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|118.44||||118.44|47.38|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.44||||118.44|59.22|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.44||||118.44|53.3|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.44||||118.44|53.3|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|118.44||||118.44|23.69|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.44||||118.44|16.58|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.44||||118.44|0|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|118.44||||118.44|81.72|81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.44||||118.44||81.72|16.58
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|118.44||||118.44|0|81.72|16.58
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|2.64||||2.64|1.19|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.06|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.06|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.24|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|1.08|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|1.19|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|1.19|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|2.64||||2.64|0.53|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|TML [1980]|TML [198000]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|0.37|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64|0|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.64||||2.64||1.82|0.37
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64|0|1.82|0.37
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.28||||5.28|2.38|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.28||||5.28|2.11|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.28||||5.28|2.11|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.28||||5.28|2.48|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|2.16|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|2.38|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.28||||5.28|2.38|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.28||||5.28|1.06|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.28||||5.28|0.74|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.28||||5.28|0|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.28||||5.28||3.64|0.74
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28|0|3.64|0.74
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AARP [1000]|AARP [100000]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|209.88||||209.88|94.45|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209.88||||209.88|104.94|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209.88||||209.88|83.95|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209.88||||209.88|83.95|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209.88||||209.88|98.64|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209.88||||209.88|86.05|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|209.88||||209.88|83.95|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209.88||||209.88|104.94|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209.88||||209.88|94.45|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209.88||||209.88|94.45|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|Self-pay|Self-pay|209.88||||209.88|41.98|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|TML [1980]|TML [198000]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209.88||||209.88|29.38|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209.88||||209.88|0|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|209.88||||209.88|144.82|144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209.88||||209.88||144.82|29.38
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|209.88||||209.88|0|144.82|29.38
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AARP [1000]|AARP [100000]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA [1015]|AETNA [101529]|1049.4||||1049.4|472.23|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMBETTER [2930]|AMBETTER [293000]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1049.4||||1049.4|524.7|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1049.4||||1049.4|419.76|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1049.4||||1049.4|419.76|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1049.4||||1049.4|493.22|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1049.4||||1049.4|430.25|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA [1260]|CIGNA PPO [126025]|1049.4||||1049.4|419.76|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1049.4||||1049.4|524.7|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1049.4||||1049.4|472.23|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1049.4||||1049.4|472.23|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|Self-pay|Self-pay|1049.4||||1049.4|209.88|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|TML [1980]|TML [198000]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1049.4||||1049.4|146.92|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNICARE [2040]|UNICARE [204000]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1049.4||||1049.4|0|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WEB TPA [2115]|WEB TPA [211500]|1049.4||||1049.4|724.09|724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1049.4||||1049.4||724.09|146.92
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WORKER'S COMP [2125]|TML WC [212537]|1049.4||||1049.4|0|724.09|146.92
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|1302.84||||1302.84|586.28|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1302.84||||1302.84|651.42|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1302.84||||1302.84|521.14|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1302.84||||1302.84|521.14|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1302.84||||1302.84|612.33|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1302.84||||1302.84|534.16|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|1302.84||||1302.84|521.14|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1302.84||||1302.84|651.42|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1302.84||||1302.84|586.28|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1302.84||||1302.84|586.28|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|Self-pay|Self-pay|1302.84||||1302.84|260.57|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1302.84||||1302.84|182.4|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1302.84||||1302.84|0|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|1302.84||||1302.84|898.96|898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1302.84||||1302.84||898.96|182.4
852|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|1302.84||||1302.84|0|898.96|182.4
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|424.38||||424.38|190.97|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|424.38||||424.38|212.19|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|424.38||||424.38|169.75|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|424.38||||424.38|169.75|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|424.38||||424.38|199.46|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|424.38||||424.38|174|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|424.38||||424.38|169.75|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|424.38||||424.38|212.19|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|424.38||||424.38|190.97|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|424.38||||424.38|190.97|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|424.38||||424.38|84.88|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|424.38||||424.38|59.41|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|424.38||||424.38|0|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|424.38||||424.38|292.82|292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|424.38||||424.38||292.82|59.41
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|424.38||||424.38|0|292.82|59.41
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|302.57||||302.57|136.16|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|302.57||||302.57|151.29|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|302.57||||302.57|121.03|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|302.57||||302.57|121.03|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|302.57||||302.57|142.21|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|302.57||||302.57|124.05|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|302.57||||302.57|121.03|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|302.57||||302.57|151.29|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|302.57||||302.57|136.16|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|302.57||||302.57|136.16|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|Self-pay|Self-pay|302.57||||302.57|60.51|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|302.57||||302.57|42.36|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|302.57||||302.57|0|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|302.57||||302.57|208.77|208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|302.57||||302.57||208.77|42.36
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|302.57||||302.57|0|208.77|42.36
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.54||||7.54|3.39|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.54||||7.54|3.77|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.54||||7.54|3.02|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.54||||7.54|3.02|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.54||||7.54|3.54|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.54||||7.54|3.09|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.54||||7.54|3.02|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.54||||7.54|3.77|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.54||||7.54|3.39|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.54||||7.54|3.39|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|Self-pay|Self-pay|7.54||||7.54|1.51|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.54||||7.54|1.06|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.54||||7.54|0|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.54||||7.54|5.2|5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.54||||7.54||5.2|1.06
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.54||||7.54|0|5.2|1.06
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AARP [1000]|AARP [100000]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AETNA [1015]|AETNA [101529]|35.8||||35.8|16.11|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AMBETTER [2930]|AMBETTER [293000]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|35.8||||35.8|17.9|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.8||||35.8|14.32|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.8||||35.8|14.32|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.8||||35.8|16.83|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|35.8||||35.8|14.68|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA PPO [126025]|35.8||||35.8|14.32|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|GROUP PENSION ADMIN [1450]|GPA [145000]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|35.8||||35.8|17.9|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.8||||35.8|16.11|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.8||||35.8|16.11|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|PHCS [1780]|PHCS MULTIPLAN [178000]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|Self-pay|Self-pay|35.8||||35.8|7.16|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|TML [1980]|TML [198000]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.8||||35.8|5.01|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|UNICARE [2040]|UNICARE [204000]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.8||||35.8|0|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|WEB TPA [2115]|WEB TPA [211500]|35.8||||35.8|24.7|24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.8||||35.8||24.7|5.01
8723|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TML WC [212537]|35.8||||35.8|0|24.7|5.01
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AARP [1000]|AARP [100000]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.17||||6.17|2.78|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.17||||6.17|3.09|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.17||||6.17|2.47|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.17||||6.17|2.47|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.17||||6.17|2.9|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.17||||6.17|2.53|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.17||||6.17|2.47|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.17||||6.17|3.09|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.17||||6.17|2.78|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.17||||6.17|2.78|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|Self-pay|Self-pay|6.17||||6.17|1.23|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|TML [1980]|TML [198000]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.17||||6.17|0.86|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.17||||6.17|0|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.17||||6.17|4.26|4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.17||||6.17||4.26|0.86
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.17||||6.17|0|4.26|0.86
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|198||||198|89.1|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|99|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|198||||198|79.2|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|198||||198|79.2|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|198||||198|93.06|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|198||||198|81.18|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|198||||198|79.2|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|99|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|89.1|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|89.1|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|198||||198|39.6|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|198||||198|27.72|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198|0|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|198||||198||136.62|27.72
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|198||||198|0|136.62|27.72
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|381.75||||381.75|171.79|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|381.75||||381.75|190.88|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.75||||381.75|152.7|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.75||||381.75|152.7|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.75||||381.75|179.42|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|381.75||||381.75|156.52|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|381.75||||381.75|152.7|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|381.75||||381.75|190.88|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.75||||381.75|171.79|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.75||||381.75|171.79|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|Self-pay|Self-pay|381.75||||381.75|76.35|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|TML [1980]|TML [198000]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.75||||381.75|53.45|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.75||||381.75|0|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|381.75||||381.75|263.41|263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.75||||381.75||263.41|53.45
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|381.75||||381.75|0|263.41|53.45
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|52.8||||52.8|23.76|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|26.4|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.8||||52.8|21.12|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.8||||52.8|21.12|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.8||||52.8|24.82|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|21.65|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|26.4|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|23.76|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|23.76|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|Self-pay|Self-pay|52.8||||52.8|10.56|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.8||||52.8|7.39|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8|0|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.8||||52.8||36.43|7.39
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8|0|36.43|7.39
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.09||||3.09|1.39|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.09||||3.09|1.55|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.09||||3.09|1.24|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.09||||3.09|1.24|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.09||||3.09|1.45|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.09||||3.09|1.27|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|3.09||||3.09|1.24|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.09||||3.09|1.55|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.09||||3.09|1.39|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.09||||3.09|1.39|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|Self-pay|Self-pay|3.09||||3.09|0.62|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|TML [1980]|TML [198000]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.09||||3.09|0.43|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.09||||3.09|0|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|3.09||||3.09|2.13|2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.09||||3.09||2.13|0.43
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|3.09||||3.09|0|2.13|0.43
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.14||||5.14|2.31|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.14||||5.14|2.57|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.14||||5.14|2.06|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.14||||5.14|2.06|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.14||||5.14|2.42|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.14||||5.14|2.11|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.14||||5.14|2.06|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.14||||5.14|2.57|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.14||||5.14|2.31|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.14||||5.14|2.31|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|Self-pay|Self-pay|5.14||||5.14|1.03|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.14||||5.14|0.72|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.14||||5.14|0|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.14||||5.14|3.55|3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.14||||5.14||3.55|0.72
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.14||||5.14|0|3.55|0.72
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|70.81||||70.81|31.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|70.81||||70.81|35.41|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.81||||70.81|28.32|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.81||||70.81|28.32|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.81||||70.81|33.28|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|70.81||||70.81|29.03|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|70.81||||70.81|28.32|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|70.81||||70.81|35.41|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.81||||70.81|31.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.81||||70.81|31.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|70.81||||70.81|14.16|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.81||||70.81|9.91|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.81||||70.81|0|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|70.81||||70.81|48.86|48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.81||||70.81||48.86|9.91
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|70.81||||70.81|0|48.86|9.91
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.58||||8.58|3.86|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.58||||8.58|4.29|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.58||||8.58|3.43|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.58||||8.58|3.43|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.58||||8.58|4.03|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.58||||8.58|3.52|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.58||||8.58|3.43|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.58||||8.58|4.29|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.58||||8.58|3.86|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.58||||8.58|3.86|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.58||||8.58|1.72|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.58||||8.58|1.2|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.58||||8.58|0|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.58||||8.58|5.92|5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.58||||8.58||5.92|1.2
8939|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACEBUTOLOL 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.58||||8.58|0|5.92|1.2
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.47||||21.47|9.66|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.47||||21.47|10.74|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.47||||21.47|8.59|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.47||||21.47|8.59|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.47||||21.47|10.09|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.47||||21.47|8.8|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.47||||21.47|8.59|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.47||||21.47|10.74|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.47||||21.47|9.66|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.47||||21.47|9.66|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|Self-pay|Self-pay|21.47||||21.47|4.29|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.47||||21.47|3.01|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.47||||21.47|0|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.47||||21.47|14.81|14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.47||||21.47||14.81|3.01
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.47||||21.47|0|14.81|3.01
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.51||||4.51|2.03|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.51||||4.51|2.26|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.51||||4.51|1.8|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.51||||4.51|1.8|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.51||||4.51|2.12|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.51||||4.51|1.85|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.51||||4.51|1.8|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.51||||4.51|2.26|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.51||||4.51|2.03|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.51||||4.51|2.03|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.51||||4.51|0.9|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.51||||4.51|0.63|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.51||||4.51|0|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.51||||4.51|3.11|3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.51||||4.51||3.11|0.63
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.51||||4.51|0|3.11|0.63
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|757.68||||757.68|340.96|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|757.68||||757.68|55.07|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|757.68||||757.68|378.84|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|757.68||||757.68|303.07|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|757.68||||757.68|303.07|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|757.68||||757.68|356.11|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|757.68||||757.68|310.65|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|757.68||||757.68|303.07|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|757.68||||757.68|378.84|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|757.68||||757.68|340.96|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|757.68||||757.68|340.96|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|757.68||||757.68|151.54|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|757.68||||757.68|53.44|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|757.68||||757.68|0|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|757.68||||757.68|522.8|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|757.68||||757.68|52.45|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|757.68||||757.68|104.9|522.8|52.45
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|757.68||||757.68|0|522.8|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AARP [1000]|AARP [100000]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|914.1||||914.1|411.35|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMBETTER [2930]|AMBETTER [293000]|914.1||||914.1|55.07|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|914.1||||914.1|457.05|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|914.1||||914.1|365.64|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|914.1||||914.1|365.64|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|914.1||||914.1|429.63|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|914.1||||914.1|374.78|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA PPO [126025]|914.1||||914.1|365.64|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|914.1||||914.1|457.05|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|914.1||||914.1|411.35|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|914.1||||914.1|411.35|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|Self-pay|Self-pay|914.1||||914.1|182.82|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|TML [1980]|TML [198000]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|914.1||||914.1|59|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNICARE [2040]|UNICARE [204000]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|914.1||||914.1|0|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WEB TPA [2115]|WEB TPA [211500]|914.1||||914.1|630.73|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|914.1||||914.1|52.45|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|914.1||||914.1|104.9|630.73|52.45
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TML WC [212537]|914.1||||914.1|0|630.73|52.45
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.88||||4.88|2.2|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.88||||4.88|2.44|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.88||||4.88|1.95|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.88||||4.88|1.95|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.88||||4.88|2.29|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.88||||4.88|2|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.88||||4.88|1.95|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.88||||4.88|2.44|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.88||||4.88|2.2|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.88||||4.88|2.2|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|4.88||||4.88|0.98|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.88||||4.88|0.68|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.88||||4.88|0|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.88||||4.88|3.37|3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.88||||4.88||3.37|0.68
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.88||||4.88|0|3.37|0.68
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AARP [1000]|AARP [100000]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AETNA [1015]|AETNA [101529]|683.1||||683.1|307.4|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMBETTER [2930]|AMBETTER [293000]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|683.1||||683.1|341.55|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|683.1||||683.1|273.24|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|683.1||||683.1|273.24|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|683.1||||683.1|321.06|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|683.1||||683.1|280.07|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA [1260]|CIGNA PPO [126025]|683.1||||683.1|273.24|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|683.1||||683.1|341.55|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|683.1||||683.1|307.4|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|683.1||||683.1|307.4|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|Self-pay|Self-pay|683.1||||683.1|136.62|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|TML [1980]|TML [198000]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|683.1||||683.1|95.63|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UNICARE [2040]|UNICARE [204000]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|683.1||||683.1|0|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WEB TPA [2115]|WEB TPA [211500]|683.1||||683.1|471.34|471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|683.1||||683.1||471.34|95.63
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WORKER'S COMP [2125]|TML WC [212537]|683.1||||683.1|0|471.34|95.63
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AARP [1000]|AARP [100000]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AETNA [1015]|AETNA [101529]|104.94||||104.94|47.22|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMBETTER [2930]|AMBETTER [293000]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104.94||||104.94|52.47|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104.94||||104.94|41.98|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104.94||||104.94|41.98|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104.94||||104.94|49.32|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104.94||||104.94|43.03|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA [1260]|CIGNA PPO [126025]|104.94||||104.94|41.98|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104.94||||104.94|52.47|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104.94||||104.94|47.22|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104.94||||104.94|47.22|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|Self-pay|Self-pay|104.94||||104.94|20.99|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|TML [1980]|TML [198000]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104.94||||104.94|14.69|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNICARE [2040]|UNICARE [204000]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104.94||||104.94|0|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WEB TPA [2115]|WEB TPA [211500]|104.94||||104.94|72.41|72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104.94||||104.94||72.41|14.69
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WORKER'S COMP [2125]|TML WC [212537]|104.94||||104.94|0|72.41|14.69
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AARP [1000]|AARP [100000]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AETNA [1015]|AETNA [101529]|52.22||||52.22|23.5|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMBETTER [2930]|AMBETTER [293000]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.22||||52.22|26.11|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.22||||52.22|20.89|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.22||||52.22|20.89|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.22||||52.22|24.54|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.22||||52.22|21.41|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA [1260]|CIGNA PPO [126025]|52.22||||52.22|20.89|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|GROUP PENSION ADMIN [1450]|GPA [145000]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.22||||52.22|26.11|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.22||||52.22|23.5|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.22||||52.22|23.5|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|PHCS [1780]|PHCS MULTIPLAN [178000]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|Self-pay|Self-pay|52.22||||52.22|10.44|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|TML [1980]|TML [198000]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.22||||52.22|7.31|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNICARE [2040]|UNICARE [204000]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.22||||52.22|0|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WEB TPA [2115]|WEB TPA [211500]|52.22||||52.22|36.03|36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.22||||52.22||36.03|7.31
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WORKER'S COMP [2125]|TML WC [212537]|52.22||||52.22|0|36.03|7.31
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|59.4||||59.4|26.73|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.4||||59.4|23.76|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.4||||59.4|23.76|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.4||||59.4|27.92|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|24.35|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|26.73|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|26.73|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|59.4||||59.4|11.88|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.4||||59.4|8.32|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4|0|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.4||||59.4||40.99|8.32
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4|0|40.99|8.32
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AARP [1000]|AARP [100000]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AETNA [1015]|AETNA [101529]|64.35||||64.35|28.96|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMBETTER [2930]|AMBETTER [293000]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.35||||64.35|32.18|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.35||||64.35|25.74|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.35||||64.35|25.74|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.35||||64.35|30.24|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.35||||64.35|26.38|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA [1260]|CIGNA PPO [126025]|64.35||||64.35|25.74|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.35||||64.35|32.18|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.35||||64.35|28.96|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.35||||64.35|28.96|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|Self-pay|Self-pay|64.35||||64.35|12.87|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|TML [1980]|TML [198000]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.35||||64.35|9.01|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNICARE [2040]|UNICARE [204000]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.35||||64.35|0|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WEB TPA [2115]|WEB TPA [211500]|64.35||||64.35|44.4|44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.35||||64.35||44.4|9.01
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WORKER'S COMP [2125]|TML WC [212537]|64.35||||64.35|0|44.4|9.01
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AARP [1000]|AARP [100000]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AETNA [1015]|AETNA [101529]|65.64||||65.64|29.54|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMBETTER [2930]|AMBETTER [293000]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|65.64||||65.64|32.82|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.64||||65.64|26.26|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.64||||65.64|26.26|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.64||||65.64|30.85|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|65.64||||65.64|26.91|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA PPO [126025]|65.64||||65.64|26.26|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|GROUP PENSION ADMIN [1450]|GPA [145000]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|65.64||||65.64|32.82|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.64||||65.64|29.54|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.64||||65.64|29.54|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|PHCS [1780]|PHCS MULTIPLAN [178000]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|Self-pay|Self-pay|65.64||||65.64|13.13|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|TML [1980]|TML [198000]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.64||||65.64|9.19|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UNICARE [2040]|UNICARE [204000]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.64||||65.64|0|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WEB TPA [2115]|WEB TPA [211500]|65.64||||65.64|45.29|45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.64||||65.64||45.29|9.19
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TML WC [212537]|65.64||||65.64|0|45.29|9.19
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|3303.3||||3303.3|1486.49|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMBETTER [2930]|AMBETTER [293000]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3303.3||||3303.3|1651.65|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3303.3||||3303.3|1321.32|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3303.3||||3303.3|1321.32|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3303.3||||3303.3|1552.55|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3303.3||||3303.3|1354.35|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|3303.3||||3303.3|1321.32|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3303.3||||3303.3|1651.65|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3303.3||||3303.3|1486.49|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3303.3||||3303.3|1486.49|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|3303.3||||3303.3|660.66|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|TML [1980]|TML [198000]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3303.3||||3303.3|462.46|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNICARE [2040]|UNICARE [204000]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3303.3||||3303.3|0|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WEB TPA [2115]|WEB TPA [211500]|3303.3||||3303.3|2279.28|2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3303.3||||3303.3||2279.28|462.46
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|3303.3||||3303.3|0|2279.28|462.46
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|81.65||||81.65|36.74|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.65||||81.65|40.83|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.65||||81.65|32.66|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.65||||81.65|32.66|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.65||||81.65|38.38|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.65||||81.65|33.48|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|81.65||||81.65|32.66|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.65||||81.65|40.83|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.65||||81.65|36.74|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.65||||81.65|36.74|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|Self-pay|Self-pay|81.65||||81.65|16.33|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.65||||81.65|11.43|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.65||||81.65|0|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|81.65||||81.65|56.34|56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.65||||81.65||56.34|11.43
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|81.65||||81.65|0|56.34|11.43
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AARP [1000]|AARP [100000]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AETNA [1015]|AETNA [101529]|1775.67||||1775.67|799.05|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1775.67||||1775.67|887.84|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1775.67||||1775.67|710.27|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1775.67||||1775.67|710.27|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1775.67||||1775.67|834.56|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1775.67||||1775.67|728.02|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|1775.67||||1775.67|710.27|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1775.67||||1775.67|887.84|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1775.67||||1775.67|799.05|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1775.67||||1775.67|799.05|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|Self-pay|Self-pay|1775.67||||1775.67|355.13|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|TML [1980]|TML [198000]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1775.67||||1775.67|248.59|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UNICARE [2040]|UNICARE [204000]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1775.67||||1775.67|0|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|1775.67||||1775.67|1225.21|1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1775.67||||1775.67||1225.21|248.59
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|1775.67||||1775.67|0|1225.21|248.59
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.93||||8.93|4.02|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.93||||8.93|4.47|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.93||||8.93|3.57|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.93||||8.93|3.57|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.93||||8.93|4.2|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.93||||8.93|3.66|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.93||||8.93|3.57|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.93||||8.93|4.47|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.93||||8.93|4.02|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.93||||8.93|4.02|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|8.93||||8.93|1.79|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.93||||8.93|1.25|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.93||||8.93|0|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.93||||8.93|6.16|6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.93||||8.93||6.16|1.25
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.93||||8.93|0|6.16|1.25
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|476.26||||476.26|214.32|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|476.26||||476.26|238.13|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|476.26||||476.26|190.5|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|476.26||||476.26|190.5|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|476.26||||476.26|223.84|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|476.26||||476.26|195.27|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|476.26||||476.26|190.5|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|476.26||||476.26|238.13|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|476.26||||476.26|214.32|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|476.26||||476.26|214.32|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|476.26||||476.26|95.25|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|476.26||||476.26|66.68|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|476.26||||476.26|0|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|476.26||||476.26|328.62|328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|476.26||||476.26||328.62|66.68
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|476.26||||476.26|0|328.62|66.68
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|765.6||||765.6|344.52|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|765.6||||765.6|382.8|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|765.6||||765.6|306.24|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|765.6||||765.6|306.24|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|765.6||||765.6|359.83|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|765.6||||765.6|313.9|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|765.6||||765.6|306.24|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|765.6||||765.6|382.8|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|765.6||||765.6|344.52|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|765.6||||765.6|344.52|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|765.6||||765.6|153.12|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|765.6||||765.6|107.18|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|765.6||||765.6|0|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|765.6||||765.6|528.26|528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|765.6||||765.6||528.26|107.18
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|765.6||||765.6|0|528.26|107.18
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AARP [1000]|AARP [100000]|3739||||3739|886|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AETNA [1015]|AETNA [101529]|3739||||3739|1682.55|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3739||||3739|1869.5|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3739||||3739|1495.6|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3739||||3739|1495.6|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3739||||3739|1757.33|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3739||||3739|1532.99|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|3739||||3739|500.15|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3739||||3739|886|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3739||||3739|1869.5|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3739||||3739|1682.55|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3739||||3739|1682.55|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3739||||3739|0|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|Self-pay|Self-pay|3739||||3739|747.8|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|TML [1980]|TML [198000]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3739||||3739|230.56|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3739||||3739|886|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UNICARE [2040]|UNICARE [204000]|3739||||3739|886|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3739||||3739|886|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|3739||||3739|2579.91|2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3739||||3739||2579.91|230.56
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|3739||||3739|886|2579.91|230.56
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AARP [1000]|AARP [100000]|2712||||2712|886|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AETNA [1015]|AETNA [101529]|2712||||2712|1220.4|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMBETTER [2930]|AMBETTER [293000]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2712||||2712|1356|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2712||||2712|1084.8|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2712||||2712|1084.8|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2712||||2712|1274.64|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2712||||2712|1111.92|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA [1260]|CIGNA PPO [126025]|2712||||2712|1084.8|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2712||||2712|886|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2712||||2712|1356|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2712||||2712|1220.4|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2712||||2712|1220.4|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2712||||2712|0|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|Self-pay|Self-pay|2712||||2712|542.4|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|TML [1980]|TML [198000]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2712||||2712|112.51|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2712||||2712|886|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UNICARE [2040]|UNICARE [204000]|2712||||2712|886|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2712||||2712|886|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WEB TPA [2115]|WEB TPA [211500]|2712||||2712|1871.28|1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2712||||2712||1871.28|112.51
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WORKER'S COMP [2125]|TML WC [212537]|2712||||2712|886|1871.28|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AARP [1000]|AARP [100000]|1885||||1885|886|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AETNA [1015]|AETNA [101529]|1885||||1885|848.25|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMBETTER [2930]|AMBETTER [293000]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1885||||1885|942.5|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1885||||1885|754|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1885||||1885|754|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1885||||1885|885.95|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1885||||1885|772.85|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA [1260]|CIGNA PPO [126025]|1885||||1885|754|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1885||||1885|886|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1885||||1885|942.5|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1885||||1885|848.25|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1885||||1885|848.25|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1885||||1885|0|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|Self-pay|Self-pay|1885||||1885|377|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|TML [1980]|TML [198000]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1885||||1885|112.51|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1885||||1885|886|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UNICARE [2040]|UNICARE [204000]|1885||||1885|886|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1885||||1885|886|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WEB TPA [2115]|WEB TPA [211500]|1885||||1885|1300.65|1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1885||||1885||1300.65|112.51
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WORKER'S COMP [2125]|TML WC [212537]|1885||||1885|886|1300.65|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AARP [1000]|AARP [100000]|1989||||1989|886|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AETNA [1015]|AETNA [101529]|1989||||1989|895.05|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AMBETTER [2930]|AMBETTER [293000]|1989||||1989|110.06|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1989||||1989|994.5|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1989||||1989|795.6|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1989||||1989|795.6|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1989||||1989|934.83|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1989||||1989|815.49|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA [1260]|CIGNA PPO [126025]|1989||||1989|500.15|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1989||||1989|886|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1989||||1989|994.5|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1989||||1989|895.05|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1989||||1989|895.05|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1989||||1989|0|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|Self-pay|Self-pay|1989||||1989|397.8|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|TML [1980]|TML [198000]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1989||||1989|112.51|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1989||||1989|886|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UNICARE [2040]|UNICARE [204000]|1989||||1989|886|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1989||||1989|886|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WEB TPA [2115]|WEB TPA [211500]|1989||||1989|1372.41|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1989||||1989|104.82|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1989||||1989|209.63|1372.41|104.82
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WORKER'S COMP [2125]|TML WC [212537]|1989||||1989|886|1372.41|104.82
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.39||||4.39|1.98|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.39||||4.39|2.2|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.39||||4.39|1.76|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.39||||4.39|1.76|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.39||||4.39|2.06|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.39||||4.39|1.8|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.39||||4.39|1.76|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.39||||4.39|2.2|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.39||||4.39|1.98|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.39||||4.39|1.98|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|4.39||||4.39|0.88|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.39||||4.39|0.61|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.39||||4.39|0|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.39||||4.39|3.03|3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.39||||4.39||3.03|0.61
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.39||||4.39|0|3.03|0.61
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|36.28||||36.28|16.33|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.28||||36.28|18.14|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.28||||36.28|14.51|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.28||||36.28|14.51|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.28||||36.28|17.05|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.28||||36.28|14.87|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|36.28||||36.28|14.51|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.28||||36.28|18.14|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.28||||36.28|16.33|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.28||||36.28|16.33|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|36.28||||36.28|7.26|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.28||||36.28|5.08|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.28||||36.28|0|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|36.28||||36.28|25.03|25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.28||||36.28||25.03|5.08
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|36.28||||36.28|0|25.03|5.08
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|26.42||||26.42|11.89|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.42||||26.42|13.21|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.42||||26.42|10.57|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.42||||26.42|10.57|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.42||||26.42|12.42|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.42||||26.42|10.83|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|26.42||||26.42|10.57|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.42||||26.42|13.21|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.42||||26.42|11.89|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.42||||26.42|11.89|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|26.42||||26.42|5.28|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|TML [1980]|TML [198000]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.42||||26.42|3.7|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.42||||26.42|0|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|26.42||||26.42|18.23|18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.42||||26.42||18.23|3.7
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|26.42||||26.42|0|18.23|3.7
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.53||||21.53|9.69|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.53||||21.53|10.77|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.53||||21.53|8.61|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.53||||21.53|8.61|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.53||||21.53|10.12|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.53||||21.53|8.83|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.53||||21.53|8.61|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.53||||21.53|10.77|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.53||||21.53|9.69|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.53||||21.53|9.69|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|Self-pay|Self-pay|21.53||||21.53|4.31|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.53||||21.53|3.01|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.53||||21.53|0|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.53||||21.53|14.86|14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.53||||21.53||14.86|3.01
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.53||||21.53|0|14.86|3.01
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.65||||19.65|8.84|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.65||||19.65|9.83|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.65||||19.65|7.86|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.65||||19.65|7.86|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.65||||19.65|9.24|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.65||||19.65|8.06|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.65||||19.65|7.86|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.65||||19.65|9.83|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.65||||19.65|8.84|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.65||||19.65|8.84|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|Self-pay|Self-pay|19.65||||19.65|3.93|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.65||||19.65|2.75|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.65||||19.65|0|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.65||||19.65|13.56|13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.65||||19.65||13.56|2.75
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.65||||19.65|0|13.56|2.75
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.07||||7.07|3.18|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.07||||7.07|3.54|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.07||||7.07|2.83|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.07||||7.07|2.83|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.07||||7.07|3.32|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.07||||7.07|2.9|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.07||||7.07|2.83|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.07||||7.07|3.54|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.07||||7.07|3.18|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.07||||7.07|3.18|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|Self-pay|Self-pay|7.07||||7.07|1.41|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.07||||7.07|0.99|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.07||||7.07|0|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.07||||7.07|4.88|4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.07||||7.07||4.88|0.99
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.07||||7.07|0|4.88|0.99
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.34||||1.34|0.6|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.34||||1.34|0.67|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.34||||1.34|0.54|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.34||||1.34|0.54|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.34||||1.34|0.63|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.34||||1.34|0.55|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.34||||1.34|0.54|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.34||||1.34|0.67|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.34||||1.34|0.6|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.34||||1.34|0.6|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.34||||1.34|0.27|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.34||||1.34|0.19|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.34||||1.34|0|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.34||||1.34|0.92|0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.34||||1.34||0.92|0.19
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.34||||1.34|0|0.92|0.19
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AARP [1000]|AARP [100000]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AETNA [1015]|AETNA [101529]|805.2||||805.2|362.34|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AMBETTER [2930]|AMBETTER [293000]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|805.2||||805.2|402.6|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|805.2||||805.2|322.08|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|805.2||||805.2|322.08|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|805.2||||805.2|378.44|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|805.2||||805.2|330.13|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|CIGNA [1260]|CIGNA PPO [126025]|805.2||||805.2|322.08|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|805.2||||805.2|402.6|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|805.2||||805.2|362.34|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|805.2||||805.2|362.34|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|Self-pay|Self-pay|805.2||||805.2|161.04|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|TML [1980]|TML [198000]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|805.2||||805.2|112.73|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|UNICARE [2040]|UNICARE [204000]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|805.2||||805.2|0|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|WEB TPA [2115]|WEB TPA [211500]|805.2||||805.2|555.59|555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|805.2||||805.2||555.59|112.73
9328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY|5 g|WORKER'S COMP [2125]|TML WC [212537]|805.2||||805.2|0|555.59|112.73
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|70.84||||70.84|31.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|70.84||||70.84|35.42|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.84||||70.84|28.34|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.84||||70.84|28.34|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.84||||70.84|33.29|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|70.84||||70.84|29.04|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|70.84||||70.84|28.34|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|70.84||||70.84|35.42|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.84||||70.84|31.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.84||||70.84|31.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|70.84||||70.84|14.17|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.84||||70.84|9.92|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.84||||70.84|0|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|70.84||||70.84|48.88|48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.84||||70.84||48.88|9.92
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|70.84||||70.84|0|48.88|9.92
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.44||||8.44|3.8|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.44||||8.44|4.22|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.44||||8.44|3.38|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.44||||8.44|3.38|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.44||||8.44|3.97|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.44||||8.44|3.46|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.44||||8.44|3.38|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.44||||8.44|4.22|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.44||||8.44|3.8|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.44||||8.44|3.8|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|Self-pay|Self-pay|8.44||||8.44|1.69|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.44||||8.44|1.18|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.44||||8.44|0|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.44||||8.44|5.82|5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.44||||8.44||5.82|1.18
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.44||||8.44|0|5.82|1.18
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.74||||0.74|0.33|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.74||||0.74|0.37|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.74||||0.74|0.3|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.74||||0.74|0.3|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.74||||0.74|0.35|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.74||||0.74|0.3|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.74||||0.74|0.3|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.74||||0.74|0.37|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.74||||0.74|0.33|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.74||||0.74|0.33|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|0.74||||0.74|0.15|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.74||||0.74|0.1|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.74||||0.74|0|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.74||||0.74|0.51|0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.74||||0.74||0.51|0.1
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.74||||0.74|0|0.51|0.1
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AARP [1000]|AARP [100000]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AETNA [1015]|AETNA [101529]|6.82||||6.82|3.07|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMBETTER [2930]|AMBETTER [293000]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.82||||6.82|3.41|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.82||||6.82|2.73|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.82||||6.82|2.73|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.82||||6.82|3.21|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.82||||6.82|2.8|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA [1260]|CIGNA PPO [126025]|6.82||||6.82|2.73|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.82||||6.82|3.41|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.82||||6.82|3.07|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.82||||6.82|3.07|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|Self-pay|Self-pay|6.82||||6.82|1.36|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|TML [1980]|TML [198000]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.82||||6.82|0.95|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNICARE [2040]|UNICARE [204000]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.82||||6.82|0|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WEB TPA [2115]|WEB TPA [211500]|6.82||||6.82|4.71|4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.82||||6.82||4.71|0.95
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WORKER'S COMP [2125]|TML WC [212537]|6.82||||6.82|0|4.71|0.95
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.68||||18.68|8.41|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.68||||18.68|9.34|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.68||||18.68|7.47|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.68||||18.68|7.47|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.68||||18.68|8.78|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.68||||18.68|7.66|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.68||||18.68|7.47|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.68||||18.68|9.34|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.68||||18.68|8.41|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.68||||18.68|8.41|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|18.68||||18.68|3.74|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.68||||18.68|2.62|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.68||||18.68|0|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.68||||18.68|12.89|12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.68||||18.68||12.89|2.62
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.68||||18.68|0|12.89|2.62
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14||||14|6.3|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14||||14|7|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14||||14|5.6|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14||||14|5.6|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14||||14|6.58|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14||||14|5.74|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14||||14|5.6|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14||||14|7|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14||||14|6.3|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14||||14|6.3|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|Self-pay|Self-pay|14||||14|2.8|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14||||14|1.96|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14||||14|0|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14||||14|9.66|9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14||||14||9.66|1.96
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14||||14|0|9.66|1.96
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.46||||3.46|1.56|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.46||||3.46|1.73|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.46||||3.46|1.38|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.46||||3.46|1.38|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.46||||3.46|1.63|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.46||||3.46|1.42|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.46||||3.46|1.38|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.46||||3.46|1.73|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.46||||3.46|1.56|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.46||||3.46|1.56|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|Self-pay|Self-pay|3.46||||3.46|0.69|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.46||||3.46|0.48|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.46||||3.46|0|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.46||||3.46|2.39|2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.46||||3.46||2.39|0.48
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.46||||3.46|0|2.39|0.48
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.82||||4.82|2.17|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.82||||4.82|2.41|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.82||||4.82|1.93|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.82||||4.82|1.93|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.82||||4.82|2.27|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.82||||4.82|1.98|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.82||||4.82|1.93|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.82||||4.82|2.41|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.82||||4.82|2.17|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.82||||4.82|2.17|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.82||||4.82|0.96|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.82||||4.82|0.67|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.82||||4.82|0|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.82||||4.82|3.33|3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.82||||4.82||3.33|0.67
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.82||||4.82|0|3.33|0.67
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.67||||6.67|3|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.67||||6.67|3.34|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.67||||6.67|2.67|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.67||||6.67|2.67|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.67||||6.67|3.13|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.67||||6.67|2.73|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.67||||6.67|2.67|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.67||||6.67|3.34|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.67||||6.67|3|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.67||||6.67|3|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|Self-pay|Self-pay|6.67||||6.67|1.33|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.67||||6.67|0.93|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.67||||6.67|0|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.67||||6.67|4.6|4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.67||||6.67||4.6|0.93
9408|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.67||||6.67|0|4.6|0.93
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AARP [1000]|AARP [100000]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.53|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMBETTER [2930]|AMBETTER [293000]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.18||||1.18|0.59|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.47|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.47|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.55|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.18||||1.18|0.48|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA PPO [126025]|1.18||||1.18|0.47|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.18||||1.18|0.59|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.53|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.53|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|Self-pay|Self-pay|1.18||||1.18|0.24|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|TML [1980]|TML [198000]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.17|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNICARE [2040]|UNICARE [204000]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18|0|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WEB TPA [2115]|WEB TPA [211500]|1.18||||1.18|0.81|0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.17
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WORKER'S COMP [2125]|TML WC [212537]|1.18||||1.18|0|0.81|0.17
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AARP [1000]|AARP [100000]|97.36||||97.36|97.36|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|97.36||||97.36|43.81|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.36||||97.36|48.68|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97.36||||97.36|38.94|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.36||||97.36|38.94|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97.36||||97.36|45.76|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97.36||||97.36|39.92|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|97.36||||97.36|38.94|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.36||||97.36|97.36|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.36||||97.36|48.68|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.36||||97.36|43.81|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.36||||97.36|43.81|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.36||||97.36|0|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|Self-pay|Self-pay|97.36||||97.36|19.47|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|TML [1980]|TML [198000]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97.36||||97.36|13.63|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.36||||97.36|97.36|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNICARE [2040]|UNICARE [204000]|97.36||||97.36|97.36|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.36||||97.36|97.36|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|97.36||||97.36|67.18|97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97.36||||97.36||97.36|13.63
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|97.36||||97.36|97.36|97.36|13.63
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AARP [1000]|AARP [100000]|94||||94|94|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|94||||94|42.3|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|94||||94|47|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|37.6|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|37.6|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|44.18|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|94||||94|38.54|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|94||||94|37.6|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|94||||94|94|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|94||||94|47|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|42.3|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|42.3|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94|0|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|Self-pay|Self-pay|94||||94|18.8|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|TML [1980]|TML [198000]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94|13.16|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94|94|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNICARE [2040]|UNICARE [204000]|94||||94|94|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94|94|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|94||||94|64.86|94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94||94|13.16
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|94||||94|94|94|13.16
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AARP [1000]|AARP [100000]|641||||641|169|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AETNA [1015]|AETNA [101529]|641||||641|288.45|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AMBETTER [2930]|AMBETTER [293000]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641||||641|320.5|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641||||641|256.4|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641||||641|256.4|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641||||641|301.27|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641||||641|262.81|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|CIGNA [1260]|CIGNA PPO [126025]|641||||641|256.4|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641||||641|169|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641||||641|320.5|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641||||641|288.45|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641||||641|288.45|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641||||641|0|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|Self-pay|Self-pay|641||||641|128.2|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|TML [1980]|TML [198000]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641||||641|89.74|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641||||641|169|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|UNICARE [2040]|UNICARE [204000]|641||||641|169|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641||||641|169|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|WEB TPA [2115]|WEB TPA [211500]|641||||641|442.29|442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|641||||641||442.29|89.74
94300422|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB W/EXERC|1|WORKER'S COMP [2125]|TML WC [212537]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AARP [1000]|AARP [100000]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AETNA [1015]|AETNA [101529]|641||||641|288.45|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AMBETTER [2930]|AMBETTER [293000]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641||||641|320.5|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641||||641|256.4|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641||||641|256.4|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641||||641|301.27|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641||||641|262.81|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|CIGNA [1260]|CIGNA PPO [126025]|641||||641|256.4|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641||||641|320.5|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641||||641|288.45|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641||||641|288.45|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641||||641|0|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|Self-pay|Self-pay|641||||641|128.2|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|TML [1980]|TML [198000]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641||||641|89.74|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|UNICARE [2040]|UNICARE [204000]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641||||641|169|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|WEB TPA [2115]|WEB TPA [211500]|641||||641|442.29|442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|641||||641||442.29|89.74
94300423|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC INTENS CARDIAC REHAB NO EXER|1|WORKER'S COMP [2125]|TML WC [212537]|641||||641|169|442.29|89.74
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AARP [1000]|AARP [100000]|482.5||||482.5|169|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AETNA [1015]|AETNA [101529]|482.5||||482.5|217.13|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMBETTER [2930]|AMBETTER [293000]|482.5||||482.5|115.88|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|482.5||||482.5|241.25|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|482.5||||482.5|193|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|482.5||||482.5|193|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|482.5||||482.5|226.78|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|482.5||||482.5|197.83|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA [1260]|CIGNA PPO [126025]|482.5||||482.5|193|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|482.5||||482.5|169|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|482.5||||482.5|241.25|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|482.5||||482.5|217.13|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|482.5||||482.5|217.13|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|482.5||||482.5|0|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|Self-pay|Self-pay|482.5||||482.5|96.5|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|TML [1980]|TML [198000]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|482.5||||482.5|67.55|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|482.5||||482.5|169|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UNICARE [2040]|UNICARE [204000]|482.5||||482.5|169|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|482.5||||482.5|169|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WEB TPA [2115]|WEB TPA [211500]|482.5||||482.5|332.93|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|482.5||||482.5|110.37|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|482.5||||482.5|220.73|332.93|67.55
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WORKER'S COMP [2125]|TML WC [212537]|482.5||||482.5|169|332.93|67.55
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AARP [1000]|AARP [100000]|769.2||||769.2|169|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AETNA [1015]|AETNA [101529]|769.2||||769.2|346.14|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMBETTER [2930]|AMBETTER [293000]|769.2||||769.2|115.88|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|769.2||||769.2|384.6|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|769.2||||769.2|307.68|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|769.2||||769.2|307.68|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|769.2||||769.2|361.52|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|769.2||||769.2|315.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA [1260]|CIGNA PPO [126025]|769.2||||769.2|307.68|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|769.2||||769.2|169|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|769.2||||769.2|384.6|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|769.2||||769.2|346.14|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|769.2||||769.2|346.14|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|769.2||||769.2|0|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|Self-pay|Self-pay|769.2||||769.2|153.84|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|TML [1980]|TML [198000]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|769.2||||769.2|107.69|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|769.2||||769.2|169|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UNICARE [2040]|UNICARE [204000]|769.2||||769.2|169|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|769.2||||769.2|169|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WEB TPA [2115]|WEB TPA [211500]|769.2||||769.2|530.75|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|769.2||||769.2|110.37|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|769.2||||769.2|220.73|530.75|107.69
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WORKER'S COMP [2125]|TML WC [212537]|769.2||||769.2|169|530.75|107.69
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|131.34||||131.34|59.1|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMBETTER [2930]|AMBETTER [293000]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131.34||||131.34|65.67|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131.34||||131.34|52.54|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131.34||||131.34|52.54|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131.34||||131.34|61.73|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131.34||||131.34|53.85|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|131.34||||131.34|52.54|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131.34||||131.34|65.67|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131.34||||131.34|59.1|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131.34||||131.34|59.1|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|131.34||||131.34|26.27|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|TML [1980]|TML [198000]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131.34||||131.34|18.39|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNICARE [2040]|UNICARE [204000]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131.34||||131.34|0|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WEB TPA [2115]|WEB TPA [211500]|131.34||||131.34|90.62|90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131.34||||131.34||90.62|18.39
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|131.34||||131.34|0|90.62|18.39
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AARP [1000]|AARP [100000]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA [1015]|AETNA [101529]|261.36||||261.36|117.61|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMBETTER [2930]|AMBETTER [293000]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|261.36||||261.36|130.68|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261.36||||261.36|104.54|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261.36||||261.36|104.54|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261.36||||261.36|122.84|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|261.36||||261.36|107.16|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|261.36||||261.36|104.54|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|261.36||||261.36|130.68|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261.36||||261.36|117.61|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261.36||||261.36|117.61|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|Self-pay|Self-pay|261.36||||261.36|52.27|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|TML [1980]|TML [198000]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261.36||||261.36|36.59|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNICARE [2040]|UNICARE [204000]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261.36||||261.36|0|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WEB TPA [2115]|WEB TPA [211500]|261.36||||261.36|180.34|180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261.36||||261.36||180.34|36.59
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|261.36||||261.36|0|180.34|36.59
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|59.4||||59.4|26.73|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.4||||59.4|23.76|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.4||||59.4|23.76|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.4||||59.4|27.92|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|24.35|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|26.73|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|26.73|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|59.4||||59.4|11.88|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.4||||59.4|8.32|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4|0|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.4||||59.4||40.99|8.32
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4|0|40.99|8.32
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|132||||132|59.4|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|66|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|52.8|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|52.8|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|62.04|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|54.12|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|66|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|59.4|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|59.4|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|132||||132|26.4|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|18.48|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|0|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132||91.08|18.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|132||||132|0|91.08|18.48
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AARP [1000]|AARP [100000]|504.5||||504.5|169|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AETNA [1015]|AETNA [101529]|504.5||||504.5|227.03|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AMBETTER [2930]|AMBETTER [293000]|504.5||||504.5|55.57|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|504.5||||504.5|252.25|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|504.5||||504.5|201.8|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|504.5||||504.5|201.8|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|504.5||||504.5|237.12|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|504.5||||504.5|206.85|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|CIGNA [1260]|CIGNA PPO [126025]|504.5||||504.5|201.8|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|504.5||||504.5|169|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|504.5||||504.5|252.25|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|504.5||||504.5|227.03|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|504.5||||504.5|227.03|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|504.5||||504.5|0|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|Self-pay|Self-pay|504.5||||504.5|100.9|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|TML [1980]|TML [198000]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|504.5||||504.5|70.63|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|504.5||||504.5|169|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|UNICARE [2040]|UNICARE [204000]|504.5||||504.5|169|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|504.5||||504.5|169|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|WEB TPA [2115]|WEB TPA [211500]|504.5||||504.5|348.11|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|504.5||||504.5|52.92|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|504.5||||504.5|105.85|348.11|52.92
94800424|EAP|0948 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC PULMONARY REHAB (COPD) W/EX 1HR|1|WORKER'S COMP [2125]|TML WC [212537]|504.5||||504.5|169|348.11|52.92
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|39.6||||39.6|17.82|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|15.84|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|15.84|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|18.61|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|16.24|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|17.82|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|17.82|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|39.6||||39.6|7.92|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|5.54|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|0|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6||27.32|5.54
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|0|27.32|5.54
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|37.81||||37.81|17.01|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.81||||37.81|18.91|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.81||||37.81|15.12|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.81||||37.81|15.12|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.81||||37.81|17.77|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.81||||37.81|15.5|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|37.81||||37.81|15.12|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.81||||37.81|18.91|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.81||||37.81|17.01|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.81||||37.81|17.01|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|37.81||||37.81|7.56|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.81||||37.81|5.29|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.81||||37.81|0|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|37.81||||37.81|26.09|26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.81||||37.81||26.09|5.29
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|37.81||||37.81|0|26.09|5.29
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|12.61||||12.61|5.67|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.61||||12.61|6.31|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.61||||12.61|5.04|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.61||||12.61|5.04|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.61||||12.61|5.93|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.61||||12.61|5.17|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|12.61||||12.61|5.04|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.61||||12.61|6.31|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.61||||12.61|5.67|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.61||||12.61|5.67|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|12.61||||12.61|2.52|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.61||||12.61|1.77|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.61||||12.61|0|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|12.61||||12.61|8.7|8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.61||||12.61||8.7|1.77
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|12.61||||12.61|0|8.7|1.77
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|49.93||||49.93|22.47|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|49.93||||49.93|24.97|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.93||||49.93|19.97|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.93||||49.93|19.97|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.93||||49.93|23.47|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|49.93||||49.93|20.47|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|49.93||||49.93|19.97|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|49.93||||49.93|24.97|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.93||||49.93|22.47|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.93||||49.93|22.47|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|Self-pay|Self-pay|49.93||||49.93|9.99|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.93||||49.93|6.99|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.93||||49.93|0|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|49.93||||49.93|34.45|34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.93||||49.93||34.45|6.99
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|49.93||||49.93|0|34.45|6.99
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.28||||4.28|1.93|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.28||||4.28|2.14|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.28||||4.28|1.71|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.28||||4.28|1.71|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.28||||4.28|2.01|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.28||||4.28|1.75|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.28||||4.28|1.71|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.28||||4.28|2.14|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.28||||4.28|1.93|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.28||||4.28|1.93|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.28||||4.28|0.86|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.28||||4.28|0.6|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.28||||4.28|0|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.28||||4.28|2.95|2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.28||||4.28||2.95|0.6
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.28||||4.28|0|2.95|0.6
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.8||||4.8|2.16|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.8||||4.8|2.4|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.8||||4.8|1.92|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.8||||4.8|1.92|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.8||||4.8|2.26|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.8||||4.8|1.97|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.8||||4.8|1.92|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.8||||4.8|2.4|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.8||||4.8|2.16|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.8||||4.8|2.16|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.8||||4.8|0.96|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.8||||4.8|0.67|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.8||||4.8|0|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.8||||4.8|3.31|3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.8||||4.8||3.31|0.67
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.8||||4.8|0|3.31|0.67
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.93||||1.93|0.87|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.93||||1.93|0.97|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.93||||1.93|0.77|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.93||||1.93|0.77|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.93||||1.93|0.91|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.93||||1.93|0.79|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.93||||1.93|0.77|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.93||||1.93|0.97|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.93||||1.93|0.87|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.93||||1.93|0.87|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.93||||1.93|0.39|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.93||||1.93|0.27|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.93||||1.93|0|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.93||||1.93|1.33|1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.93||||1.93||1.33|0.27
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.93||||1.93|0|1.33|0.27
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AARP [1000]|AARP [100000]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AARP [1000]|AARP [100000]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA [1015]|AETNA [101529]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA [1015]|AETNA [101529]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMBETTER [2930]|AMBETTER [293000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMBETTER [2930]|AMBETTER [293000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.15||||25.15|12.58|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.15||||25.15|12.58|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.15||||25.15|11.82|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.15||||25.15|11.82|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.15||||25.15|10.31|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.15||||25.15|10.31|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA PPO [126025]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA PPO [126025]|25.15||||25.15|10.06|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.15||||25.15|12.58|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.15||||25.15|12.58|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.15||||25.15|11.32|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|Self-pay|Self-pay|25.15||||25.15|5.03|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|Self-pay|Self-pay|25.15||||25.15|5.03|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|TML [1980]|TML [198000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|TML [1980]|TML [198000]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.15||||25.15|3.52|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.15||||25.15|3.52|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNICARE [2040]|UNICARE [204000]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNICARE [2040]|UNICARE [204000]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WEB TPA [2115]|WEB TPA [211500]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WEB TPA [2115]|WEB TPA [211500]|25.15||||25.15|17.35|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.15||||25.15||17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TML WC [212537]|25.15||||25.15|0|17.35|3.52
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TML WC [212537]|25.15||||25.15|0|17.35|3.52
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|3929.64||||3929.64|1768.34|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3929.64||||3929.64|1964.82|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3929.64||||3929.64|1571.86|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3929.64||||3929.64|1571.86|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3929.64||||3929.64|1846.93|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3929.64||||3929.64|1611.15|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|3929.64||||3929.64|1571.86|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3929.64||||3929.64|1964.82|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3929.64||||3929.64|1768.34|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3929.64||||3929.64|1768.34|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|3929.64||||3929.64|785.93|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3929.64||||3929.64|550.15|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3929.64||||3929.64|0|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|3929.64||||3929.64|2711.45|2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3929.64||||3929.64||2711.45|550.15
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|3929.64||||3929.64|0|2711.45|550.15
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|184.8||||184.8|83.16|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.8||||184.8|92.4|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184.8||||184.8|73.92|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184.8||||184.8|73.92|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184.8||||184.8|86.86|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.8||||184.8|75.77|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|184.8||||184.8|73.92|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.8||||184.8|92.4|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.8||||184.8|83.16|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.8||||184.8|83.16|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|184.8||||184.8|36.96|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184.8||||184.8|25.87|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184.8||||184.8|0|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|184.8||||184.8|127.51|127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184.8||||184.8||127.51|25.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|184.8||||184.8|0|127.51|25.87
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.9||||12.9|5.81|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.9||||12.9|6.45|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.9||||12.9|5.16|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.9||||12.9|5.16|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.9||||12.9|6.06|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.9||||12.9|5.29|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.9||||12.9|5.16|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.9||||12.9|6.45|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.9||||12.9|5.81|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.9||||12.9|5.81|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|12.9||||12.9|2.58|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.9||||12.9|1.81|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.9||||12.9|0|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.9||||12.9|8.9|8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.9||||12.9||8.9|1.81
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.9||||12.9|0|8.9|1.81
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|103.62||||103.62|46.63|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103.62||||103.62|51.81|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103.62||||103.62|41.45|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103.62||||103.62|41.45|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103.62||||103.62|48.7|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103.62||||103.62|42.48|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|103.62||||103.62|41.45|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103.62||||103.62|51.81|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103.62||||103.62|46.63|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103.62||||103.62|46.63|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|103.62||||103.62|20.72|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103.62||||103.62|14.51|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103.62||||103.62|0|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|103.62||||103.62|71.5|71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103.62||||103.62||71.5|14.51
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|103.62||||103.62|0|71.5|14.51
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|156.42||||156.42|70.39|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|156.42||||156.42|78.21|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156.42||||156.42|62.57|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156.42||||156.42|62.57|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156.42||||156.42|73.52|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|156.42||||156.42|64.13|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|156.42||||156.42|62.57|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|156.42||||156.42|78.21|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156.42||||156.42|70.39|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156.42||||156.42|70.39|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|156.42||||156.42|31.28|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156.42||||156.42|21.9|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156.42||||156.42|0|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|156.42||||156.42|107.93|107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156.42||||156.42||107.93|21.9
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|156.42||||156.42|0|107.93|21.9
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|172.26||||172.26|77.52|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|172.26||||172.26|86.13|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|172.26||||172.26|68.9|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|172.26||||172.26|68.9|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|172.26||||172.26|80.96|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|172.26||||172.26|70.63|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|172.26||||172.26|68.9|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|172.26||||172.26|86.13|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|172.26||||172.26|77.52|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|172.26||||172.26|77.52|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|172.26||||172.26|34.45|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|172.26||||172.26|24.12|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|172.26||||172.26|0|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|172.26||||172.26|118.86|118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|172.26||||172.26||118.86|24.12
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|172.26||||172.26|0|118.86|24.12
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.57||||0.57|0.26|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.57||||0.57|0.29|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.57||||0.57|0.23|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.57||||0.57|0.23|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.57||||0.57|0.27|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.57||||0.57|0.23|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.57||||0.57|0.23|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.57||||0.57|0.29|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.57||||0.57|0.26|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.57||||0.57|0.26|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.57||||0.57|0.11|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.57||||0.57|0.08|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.57||||0.57|0|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.57||||0.57|0.39|0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.57||||0.57||0.39|0.08
9638|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.57||||0.57|0|0.39|0.08
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AARP [1000]|AARP [100000]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA [1015]|AETNA [101529]|16.98||||16.98|7.64|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.98||||16.98|8.49|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.98||||16.98|6.79|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.98||||16.98|6.79|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.98||||16.98|7.98|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.98||||16.98|6.96|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.98||||16.98|6.79|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.98||||16.98|8.49|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.98||||16.98|7.64|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.98||||16.98|7.64|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|Self-pay|Self-pay|16.98||||16.98|3.4|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|TML [1980]|TML [198000]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.98||||16.98|2.38|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNICARE [2040]|UNICARE [204000]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.98||||16.98|0|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.98||||16.98|11.72|11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.98||||16.98||11.72|2.38
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|16.98||||16.98|0|11.72|2.38
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AARP [1000]|AARP [100000]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AETNA [1015]|AETNA [101529]|3447.98||||3447.98|1551.59|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AMBETTER [2930]|AMBETTER [293000]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3447.98||||3447.98|1723.99|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3447.98||||3447.98|1379.19|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3447.98||||3447.98|1379.19|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3447.98||||3447.98|1620.55|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3447.98||||3447.98|1413.67|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|CIGNA [1260]|CIGNA PPO [126025]|3447.98||||3447.98|1379.19|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3447.98||||3447.98|1723.99|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3447.98||||3447.98|1551.59|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3447.98||||3447.98|1551.59|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|Self-pay|Self-pay|3447.98||||3447.98|689.6|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|TML [1980]|TML [198000]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3447.98||||3447.98|482.72|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|UNICARE [2040]|UNICARE [204000]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3447.98||||3447.98|0|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|WEB TPA [2115]|WEB TPA [211500]|3447.98||||3447.98|2379.11|2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3447.98||||3447.98||2379.11|482.72
9682|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT|30 g|WORKER'S COMP [2125]|TML WC [212537]|3447.98||||3447.98|0|2379.11|482.72
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AARP [1000]|AARP [100000]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AETNA [1015]|AETNA [101529]|1406.86||||1406.86|633.09|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMBETTER [2930]|AMBETTER [293000]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1406.86||||1406.86|703.43|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1406.86||||1406.86|562.74|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1406.86||||1406.86|562.74|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1406.86||||1406.86|661.22|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1406.86||||1406.86|576.81|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA [1260]|CIGNA PPO [126025]|1406.86||||1406.86|562.74|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1406.86||||1406.86|703.43|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1406.86||||1406.86|633.09|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1406.86||||1406.86|633.09|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|Self-pay|Self-pay|1406.86||||1406.86|281.37|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|TML [1980]|TML [198000]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1406.86||||1406.86|196.96|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNICARE [2040]|UNICARE [204000]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1406.86||||1406.86|0|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WEB TPA [2115]|WEB TPA [211500]|1406.86||||1406.86|970.73|970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1406.86||||1406.86||970.73|196.96
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WORKER'S COMP [2125]|TML WC [212537]|1406.86||||1406.86|0|970.73|196.96
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|226.02||||226.02|101.71|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|226.02||||226.02|113.01|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|226.02||||226.02|90.41|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|226.02||||226.02|90.41|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|226.02||||226.02|106.23|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|226.02||||226.02|92.67|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|226.02||||226.02|90.41|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|226.02||||226.02|113.01|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|226.02||||226.02|101.71|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|226.02||||226.02|101.71|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|226.02||||226.02|45.2|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|226.02||||226.02|31.64|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|226.02||||226.02|0|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|226.02||||226.02|155.95|155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|226.02||||226.02||155.95|31.64
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|226.02||||226.02|0|155.95|31.64
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1078.71||||1078.71|485.42|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1078.71||||1078.71|539.36|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1078.71||||1078.71|431.48|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1078.71||||1078.71|431.48|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1078.71||||1078.71|506.99|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1078.71||||1078.71|442.27|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1078.71||||1078.71|431.48|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1078.71||||1078.71|539.36|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1078.71||||1078.71|485.42|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1078.71||||1078.71|485.42|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|1078.71||||1078.71|215.74|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1078.71||||1078.71|151.02|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1078.71||||1078.71|0|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1078.71||||1078.71|744.31|744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1078.71||||1078.71||744.31|151.02
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1078.71||||1078.71|0|744.31|151.02
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AARP [1000]|AARP [100000]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AETNA [1015]|AETNA [101529]|311.66||||311.66|140.25|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AMBETTER [2930]|AMBETTER [293000]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|311.66||||311.66|155.83|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311.66||||311.66|124.66|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311.66||||311.66|124.66|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311.66||||311.66|146.48|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|311.66||||311.66|127.78|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA PPO [126025]|311.66||||311.66|124.66|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|311.66||||311.66|155.83|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311.66||||311.66|140.25|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311.66||||311.66|140.25|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|Self-pay|Self-pay|311.66||||311.66|62.33|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|TML [1980]|TML [198000]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311.66||||311.66|43.63|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|UNICARE [2040]|UNICARE [204000]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311.66||||311.66|0|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|WEB TPA [2115]|WEB TPA [211500]|311.66||||311.66|215.05|215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|311.66||||311.66||215.05|43.63
9700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 2 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TML WC [212537]|311.66||||311.66|0|215.05|43.63
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|33.4||||33.4|15.03|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33.4||||33.4|16.7|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.4||||33.4|13.36|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.4||||33.4|13.36|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.4||||33.4|15.7|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33.4||||33.4|13.69|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|33.4||||33.4|13.36|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33.4||||33.4|16.7|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.4||||33.4|15.03|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.4||||33.4|15.03|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|Self-pay|Self-pay|33.4||||33.4|6.68|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.4||||33.4|4.68|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.4||||33.4|0|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|33.4||||33.4|23.05|23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.4||||33.4||23.05|4.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|33.4||||33.4|0|23.05|4.68
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|21.49||||21.49|9.67|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.49||||21.49|10.75|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.49||||21.49|8.6|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.49||||21.49|8.6|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.49||||21.49|10.1|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.49||||21.49|8.81|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|21.49||||21.49|8.6|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.49||||21.49|10.75|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.49||||21.49|9.67|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.49||||21.49|9.67|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|21.49||||21.49|4.3|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.49||||21.49|3.01|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.49||||21.49|0|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|21.49||||21.49|14.83|14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.49||||21.49||14.83|3.01
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|21.49||||21.49|0|14.83|3.01
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|83.23||||83.23|37.45|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.23||||83.23|41.62|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.23||||83.23|33.29|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.23||||83.23|33.29|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.23||||83.23|39.12|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.23||||83.23|34.12|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|83.23||||83.23|33.29|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.23||||83.23|41.62|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.23||||83.23|37.45|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.23||||83.23|37.45|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|83.23||||83.23|16.65|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.23||||83.23|11.65|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.23||||83.23|0|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|83.23||||83.23|57.43|57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.23||||83.23||57.43|11.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|83.23||||83.23|0|57.43|11.65
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|646.8||||646.8|291.06|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|646.8||||646.8|323.4|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|646.8||||646.8|258.72|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|646.8||||646.8|258.72|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|646.8||||646.8|304|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|646.8||||646.8|265.19|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|646.8||||646.8|258.72|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|646.8||||646.8|323.4|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|646.8||||646.8|291.06|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|646.8||||646.8|291.06|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|Self-pay|Self-pay|646.8||||646.8|129.36|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|TML [1980]|TML [198000]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|646.8||||646.8|90.55|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|646.8||||646.8|0|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|646.8||||646.8|446.29|446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|646.8||||646.8||446.29|90.55
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|646.8||||646.8|0|446.29|90.55
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AARP [1000]|AARP [100000]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AETNA [1015]|AETNA [101529]|127.91||||127.91|57.56|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMBETTER [2930]|AMBETTER [293000]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|127.91||||127.91|63.96|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|127.91||||127.91|51.16|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|127.91||||127.91|51.16|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|127.91||||127.91|60.12|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|127.91||||127.91|52.44|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA [1260]|CIGNA PPO [126025]|127.91||||127.91|51.16|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|GROUP PENSION ADMIN [1450]|GPA [145000]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|127.91||||127.91|63.96|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|127.91||||127.91|57.56|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|127.91||||127.91|57.56|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|PHCS [1780]|PHCS MULTIPLAN [178000]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|Self-pay|Self-pay|127.91||||127.91|25.58|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|TML [1980]|TML [198000]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|127.91||||127.91|17.91|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNICARE [2040]|UNICARE [204000]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|127.91||||127.91|0|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WEB TPA [2115]|WEB TPA [211500]|127.91||||127.91|88.26|88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|127.91||||127.91||88.26|17.91
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WORKER'S COMP [2125]|TML WC [212537]|127.91||||127.91|0|88.26|17.91
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|3307.4||||3307.4|1488.33|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3307.4||||3307.4|1653.7|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3307.4||||3307.4|1322.96|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3307.4||||3307.4|1322.96|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3307.4||||3307.4|1554.48|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3307.4||||3307.4|1356.03|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|3307.4||||3307.4|1322.96|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3307.4||||3307.4|1653.7|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3307.4||||3307.4|1488.33|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3307.4||||3307.4|1488.33|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|3307.4||||3307.4|661.48|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3307.4||||3307.4|463.04|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3307.4||||3307.4|0|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|3307.4||||3307.4|2282.11|2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3307.4||||3307.4||2282.11|463.04
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|3307.4||||3307.4|0|2282.11|463.04
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7123.29||||7123.29|3205.48|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7123.29||||7123.29|3561.65|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7123.29||||7123.29|2849.32|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7123.29||||7123.29|2849.32|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7123.29||||7123.29|3347.95|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7123.29||||7123.29|2920.55|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7123.29||||7123.29|2849.32|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7123.29||||7123.29|3561.65|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7123.29||||7123.29|3205.48|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7123.29||||7123.29|3205.48|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|Self-pay|Self-pay|7123.29||||7123.29|1424.66|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7123.29||||7123.29|997.26|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7123.29||||7123.29|0|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7123.29||||7123.29|4915.07|4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7123.29||||7123.29||4915.07|997.26
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7123.29||||7123.29|0|4915.07|997.26
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|41.58|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|36.96|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|36.96|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|43.43|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|37.88|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|41.58|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|41.58|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|12.94|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|0|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4||63.76|12.94
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|0|63.76|12.94
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|29.7|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|26.4|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|26.4|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|31.02|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|27.06|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|29.7|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|29.7|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|66||||66|13.2|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|9.24|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|0|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.24
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|0|45.54|9.24
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.15||||3.15|1.42|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.15||||3.15|1.58|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.15||||3.15|1.26|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.15||||3.15|1.26|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.15||||3.15|1.48|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.15||||3.15|1.29|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.15||||3.15|1.26|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.15||||3.15|1.58|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.15||||3.15|1.42|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.15||||3.15|1.42|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|3.15||||3.15|0.63|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.15||||3.15|0.44|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.15||||3.15|0|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.15||||3.15|2.17|2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.15||||3.15||2.17|0.44
98361|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE ER 142 MG (45 MG IRON) TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.15||||3.15|0|2.17|0.44
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.89||||10.89|4.9|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.89||||10.89|5.45|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.89||||10.89|4.36|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.89||||10.89|4.36|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.89||||10.89|5.12|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.89||||10.89|4.46|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.89||||10.89|4.36|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.89||||10.89|5.45|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.89||||10.89|4.9|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.89||||10.89|4.9|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|Self-pay|Self-pay|10.89||||10.89|2.18|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.89||||10.89|1.52|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.89||||10.89|0|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.89||||10.89|7.51|7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.89||||10.89||7.51|1.52
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.89||||10.89|4.9|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.89||||10.89|5.45|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.89||||10.89|4.36|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.89||||10.89|4.36|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.89||||10.89|5.12|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.89||||10.89|4.46|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.89||||10.89|4.36|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.89||||10.89|5.45|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.89||||10.89|4.9|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.89||||10.89|4.9|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|Self-pay|Self-pay|10.89||||10.89|2.18|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.89||||10.89|1.52|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.89||||10.89|0|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.89||||10.89|7.51|7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.89||||10.89||7.51|1.52
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.89||||10.89|0|7.51|1.52
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.96||||3.96|1.78|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.96||||3.96|1.98|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.96||||3.96|1.58|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.96||||3.96|1.58|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.96||||3.96|1.86|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.96||||3.96|1.62|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|3.96||||3.96|1.58|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.96||||3.96|1.98|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.96||||3.96|1.78|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.96||||3.96|1.78|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.96||||3.96|0.79|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.96||||3.96|0.55|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.96||||3.96|0|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|3.96||||3.96|2.73|2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.96||||3.96||2.73|0.55
988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZONATATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|3.96||||3.96|0|2.73|0.55
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.67||||10.67|4.8|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.67||||10.67|5.34|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.67||||10.67|4.27|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.67||||10.67|4.27|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.67||||10.67|5.01|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.67||||10.67|4.37|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.67||||10.67|4.27|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.67||||10.67|5.34|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.67||||10.67|4.8|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.67||||10.67|4.8|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|Self-pay|Self-pay|10.67||||10.67|2.13|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.67||||10.67|1.49|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.67||||10.67|0|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.67||||10.67|7.36|7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.67||||10.67||7.36|1.49
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.67||||10.67|0|7.36|1.49
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|68.01||||68.01|30.6|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|68.01||||68.01|34.01|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.01||||68.01|27.2|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.01||||68.01|27.2|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.01||||68.01|31.96|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|68.01||||68.01|27.88|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|68.01||||68.01|27.2|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|68.01||||68.01|34.01|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.01||||68.01|30.6|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.01||||68.01|30.6|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|68.01||||68.01|13.6|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.01||||68.01|9.52|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.01||||68.01|0|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|68.01||||68.01|46.93|46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.01||||68.01||46.93|9.52
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|68.01||||68.01|0|46.93|9.52
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.3||||6.3|2.84|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.3||||6.3|3.15|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.3||||6.3|2.52|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.3||||6.3|2.52|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.3||||6.3|2.96|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.3||||6.3|2.58|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.3||||6.3|2.52|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.3||||6.3|3.15|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.3||||6.3|2.84|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.3||||6.3|2.84|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|6.3||||6.3|1.26|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.3||||6.3|0.88|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.3||||6.3|0|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.3||||6.3|4.35|4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.3||||6.3||4.35|0.88
9927|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.3||||6.3|0|4.35|0.88
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|63.77||||63.77|28.7|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|63.77||||63.77|31.89|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.77||||63.77|25.51|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.77||||63.77|25.51|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.77||||63.77|29.97|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|63.77||||63.77|26.15|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|63.77||||63.77|25.51|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|63.77||||63.77|31.89|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.77||||63.77|28.7|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.77||||63.77|28.7|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|63.77||||63.77|12.75|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|TML [1980]|TML [198000]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.77||||63.77|8.93|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.77||||63.77|0|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|63.77||||63.77|44|44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.77||||63.77||44|8.93
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|63.77||||63.77|0|44|8.93
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.06||||4.06|1.83|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.06||||4.06|2.03|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.06||||4.06|1.62|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.06||||4.06|1.62|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.06||||4.06|1.91|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.06||||4.06|1.66|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.06||||4.06|1.62|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.06||||4.06|2.03|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.06||||4.06|1.83|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.06||||4.06|1.83|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|4.06||||4.06|0.81|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.06||||4.06|0.57|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.06||||4.06|0|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.06||||4.06|2.8|2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.06||||4.06||2.8|0.57
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.06||||4.06|0|2.8|0.57
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AARP [1000]|AARP [100000]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AETNA [1015]|AETNA [101529]|3275.68||||3275.68|1474.06|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AMBETTER [2930]|AMBETTER [293000]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3275.68||||3275.68|1637.84|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3275.68||||3275.68|1310.27|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3275.68||||3275.68|1310.27|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3275.68||||3275.68|1539.57|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3275.68||||3275.68|1343.03|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA [1260]|CIGNA PPO [126025]|3275.68||||3275.68|1310.27|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3275.68||||3275.68|1637.84|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3275.68||||3275.68|1474.06|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3275.68||||3275.68|1474.06|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|Self-pay|Self-pay|3275.68||||3275.68|655.14|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|TML [1980]|TML [198000]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3275.68||||3275.68|458.6|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UNICARE [2040]|UNICARE [204000]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3275.68||||3275.68|0|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WEB TPA [2115]|WEB TPA [211500]|3275.68||||3275.68|2260.22|2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3275.68||||3275.68||2260.22|458.6
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WORKER'S COMP [2125]|TML WC [212537]|3275.68||||3275.68|0|2260.22|458.6
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|83.6||||83.6|37.62|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.6||||83.6|41.8|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.6||||83.6|33.44|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.6||||83.6|33.44|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.6||||83.6|39.29|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.6||||83.6|34.28|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|83.6||||83.6|33.44|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.6||||83.6|41.8|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.6||||83.6|37.62|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.6||||83.6|37.62|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|83.6||||83.6|16.72|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.6||||83.6|11.7|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.6||||83.6|0|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|83.6||||83.6|57.68|57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.6||||83.6||57.68|11.7
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|83.6||||83.6|0|57.68|11.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|81.83||||81.83|36.82|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.83||||81.83|40.92|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.83||||81.83|32.73|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.83||||81.83|32.73|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.83||||81.83|38.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.83||||81.83|33.55|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|81.83||||81.83|32.73|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.83||||81.83|40.92|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.83||||81.83|36.82|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.83||||81.83|36.82|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|Self-pay|Self-pay|81.83||||81.83|16.37|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|TML [1980]|TML [198000]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.83||||81.83|11.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.83||||81.83|0|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|81.83||||81.83|56.46|56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.83||||81.83||56.46|11.46
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|81.83||||81.83|36.82|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.83||||81.83|40.92|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.83||||81.83|32.73|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.83||||81.83|32.73|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.83||||81.83|38.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.83||||81.83|33.55|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|81.83||||81.83|32.73|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.83||||81.83|40.92|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.83||||81.83|36.82|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.83||||81.83|36.82|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|Self-pay|Self-pay|81.83||||81.83|16.37|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|TML [1980]|TML [198000]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.83||||81.83|11.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.83||||81.83|0|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|81.83||||81.83|56.46|56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.83||||81.83||56.46|11.46
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|81.83||||81.83|0|56.46|11.46
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AARP [1000]|AARP [100000]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AETNA [1015]|AETNA [101529]|5332.94||||5332.94|2399.82|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMBETTER [2930]|AMBETTER [293000]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5332.94||||5332.94|2666.47|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5332.94||||5332.94|2133.18|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5332.94||||5332.94|2133.18|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5332.94||||5332.94|2506.48|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5332.94||||5332.94|2186.51|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA [1260]|CIGNA PPO [126025]|5332.94||||5332.94|2133.18|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5332.94||||5332.94|2666.47|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5332.94||||5332.94|2399.82|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5332.94||||5332.94|2399.82|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|Self-pay|Self-pay|5332.94||||5332.94|1066.59|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|TML [1980]|TML [198000]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5332.94||||5332.94|746.61|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNICARE [2040]|UNICARE [204000]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5332.94||||5332.94|0|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WEB TPA [2115]|WEB TPA [211500]|5332.94||||5332.94|3679.73|3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5332.94||||5332.94||3679.73|746.61
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WORKER'S COMP [2125]|TML WC [212537]|5332.94||||5332.94|0|3679.73|746.61
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.3||||10.3|4.64|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.3||||10.3|5.15|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.3||||10.3|4.12|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.3||||10.3|4.12|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.3||||10.3|4.84|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.3||||10.3|4.22|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.3||||10.3|4.12|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.3||||10.3|5.15|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.3||||10.3|4.64|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.3||||10.3|4.64|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|Self-pay|Self-pay|10.3||||10.3|2.06|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.3||||10.3|1.44|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.3||||10.3|0|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.3||||10.3|7.11|7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.3||||10.3||7.11|1.44
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.3||||10.3|0|7.11|1.44
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.47||||6.47|2.91|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.47||||6.47|3.24|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.47||||6.47|2.59|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.47||||6.47|2.59|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.47||||6.47|3.04|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.47||||6.47|2.65|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.47||||6.47|2.59|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.47||||6.47|3.24|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.47||||6.47|2.91|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.47||||6.47|2.91|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|6.47||||6.47|1.29|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.47||||6.47|0.91|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.47||||6.47|0|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.47||||6.47|4.46|4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.47||||6.47||4.46|0.91
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.47||||6.47|0|4.46|0.91
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AARP [1000]|AARP [100000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AETNA [1015]|AETNA [101529]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AMBETTER [2930]|AMBETTER [293000]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|CIGNA [1260]|CIGNA PPO [126025]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|Self-pay|Self-pay|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|TML [1980]|TML [198000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|UNICARE [2040]|UNICARE [204000]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|WEB TPA [2115]|WEB TPA [211500]|0||||0|0||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0||||0|||
99900089|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT 15 MINUTE STATISTIC|1|WORKER'S COMP [2125]|TML WC [212537]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AARP [1000]|AARP [100000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AETNA [1015]|AETNA [101529]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AMBETTER [2930]|AMBETTER [293000]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|CIGNA [1260]|CIGNA PPO [126025]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|Self-pay|Self-pay|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|TML [1980]|TML [198000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|UNICARE [2040]|UNICARE [204000]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|WEB TPA [2115]|WEB TPA [211500]|0||||0|0||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0||||0|||
99900090|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT ASSIST/15 MIN STATISTIC|1|WORKER'S COMP [2125]|TML WC [212537]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AARP [1000]|AARP [100000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AETNA [1015]|AETNA [101529]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AMBETTER [2930]|AMBETTER [293000]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|CIGNA [1260]|CIGNA PPO [126025]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|Self-pay|Self-pay|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|TML [1980]|TML [198000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|UNICARE [2040]|UNICARE [204000]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|WEB TPA [2115]|WEB TPA [211500]|0||||0|0||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0||||0|||
99900094|EAP|0999 - PATIENT CONVENIENCE ITEMS-OTHER CONVENIENCE|HC RT PATIENT EDUCATION|1|WORKER'S COMP [2125]|TML WC [212537]|0||||0|0||